Provider Demographics
NPI:1881987329
Name:O'DELL, NICHOLAS CARSON (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:CARSON
Last Name:O'DELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S 8TH ST
Mailing Address - Street 2:SUITE 480W
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2400
Mailing Address - Country:US
Mailing Address - Phone:270-762-1515
Mailing Address - Fax:270-752-2852
Practice Address - Street 1:803 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2432
Practice Address - Country:US
Practice Address - Phone:270-762-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47279207R00000X
KYTP665207R00000X
KYR2806207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100058500Medicaid
KYK140140Medicare PIN