Provider Demographics
NPI:1295767218
Name:ODOM, GEOFFREY LYLE (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:LYLE
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2668
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2668
Mailing Address - Country:US
Mailing Address - Phone:985-230-1369
Mailing Address - Fax:985-230-1368
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:FINANCE DEPARTMENT
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-230-1369
Practice Address - Fax:985-230-1368
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.023178207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07972078Medicaid
LA1492418Medicaid
G65516Medicare UPIN
LA1492418Medicaid