Provider Demographics
NPI:1740625870
Name:ODOM SPORTS MEDICINE, P.A.
Entity type:Organization
Organization Name:ODOM SPORTS MEDICINE, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HL
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:952-224-1919
Mailing Address - Street 1:10500 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1511
Mailing Address - Country:US
Mailing Address - Phone:952-224-1919
Mailing Address - Fax:
Practice Address - Street 1:500 S CHERRY ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-4515
Practice Address - Country:US
Practice Address - Phone:952-856-4722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ODOM SPORTS MEDICINE, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty