Provider Demographics
NPI:1700175536
Name:ODOM, MICHAEL RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RYAN
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2349
Practice Address - Street 1:14402 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2167
Practice Address - Country:US
Practice Address - Phone:509-922-2625
Practice Address - Fax:877-521-3642
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00995207Q00000X
IA48734207Q00000X
NE26919207Q00000X
NV16240207Q00000X
IDM-15606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine