Basic Information
| Provider Information | |||||||||
| NPI: | 1003889387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432927331 | ||||||||
| FaxNumber: | 8432927324 | ||||||||
| Practice Location | |||||||||
| Address1: | 3032 E HIGHWAY 76 | ||||||||
| Address2: | |||||||||
| City: | MULLINS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295747396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432927331 | ||||||||
| FaxNumber: | 8432927324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 03/26/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16250 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | T10501 | 05 | SC | MEDICAID |