Provider Demographics
NPI:1295803195
Name:ODOM, AUBREY ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:AUBREY
Middle Name:ALAN
Last Name:ODOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401-3320
Mailing Address - Country:US
Mailing Address - Phone:251-578-2922
Mailing Address - Fax:251-578-2952
Practice Address - Street 1:109 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:AL
Practice Address - Zip Code:36401-3320
Practice Address - Country:US
Practice Address - Phone:251-578-2922
Practice Address - Fax:251-578-2952
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-860-TA-413152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000034940Medicaid
AL000034940Medicaid
AL51034940ODOMedicare ID - Type Unspecified