Basic Information
| Provider Information | |||||||||
| NPI: | 1073592457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODEWALD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C, PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 758963 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212758963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049685700 | ||||||||
| FaxNumber: | 8042177991 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 NEWTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574738400 | ||||||||
| FaxNumber: | 7574730712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
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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 | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.