Provider Demographics
NPI:1700079779
Name:ODELL, WILLIAM ALLAN
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ALLAN
Last Name:ODELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 14TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-6916
Mailing Address - Country:US
Mailing Address - Phone:641-423-0279
Mailing Address - Fax:
Practice Address - Street 1:931 14TH ST SE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-6916
Practice Address - Country:US
Practice Address - Phone:641-423-0279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1323Medicaid