Provider Demographics
NPI:1770525107
Name:ODOM, STEPHEN G (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1005 N TENNESSEE BLVD
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-2653
Mailing Address - Country:US
Mailing Address - Phone:615-893-1615
Mailing Address - Fax:615-893-2747
Practice Address - Street 1:1005 N TENNESSEE BLVD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2653
Practice Address - Country:US
Practice Address - Phone:615-893-1615
Practice Address - Fax:615-893-2747
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN6332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3156890Medicaid
TN2604322OtherCIGNA
44D0307626OtherCLIA ID NUMBER
TN2006264OtherBLUE CROSS
TN2604322OtherCIGNA
B02652Medicare UPIN