Provider Demographics
NPI:1952320756
Name:ODOM, TIMOTHY E (D C)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:E
Last Name:ODOM
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5521 BELLAIRE DR S
Mailing Address - Street 2:STE. 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-8838
Mailing Address - Country:US
Mailing Address - Phone:817-723-4441
Mailing Address - Fax:817-732-2472
Practice Address - Street 1:5521 BELLAIRE DR S
Practice Address - Street 2:STE. 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-8838
Practice Address - Country:US
Practice Address - Phone:817-723-4441
Practice Address - Fax:817-732-2472
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5994111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2306040318Medicaid
TXTXB156610Medicare PIN
TX2306040318Medicaid
TX604031Medicare ID - Type Unspecified