Provider Demographics
NPI:1740293794
Name:ODOM, JAMES GRAYDON (MS)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:GRAYDON
Last Name:ODOM
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 MEMORIAL DR
Mailing Address - Street 2:AUDIOLOGY 126W
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76711-1329
Mailing Address - Country:US
Mailing Address - Phone:254-297-3603
Mailing Address - Fax:
Practice Address - Street 1:4800 MEMORIAL DR
Practice Address - Street 2:AUDIOLOGY 126W
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1329
Practice Address - Country:US
Practice Address - Phone:254-297-3603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50511231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist