Basic Information
| Provider Information | |||||||||
| NPI: | 1093815474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | CECIL | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 RIVER OAKS DRIVE, | ||||||||
| Address2: | STE 310 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019325006 | ||||||||
| FaxNumber: | 6019324548 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 RIVER OAKS DRIVE, | ||||||||
| Address2: | STE 310 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019325006 | ||||||||
| FaxNumber: | 6019324548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
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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 | 207VG0400X | 05821 | MS | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00017818 | 05 | MS | MEDICAID |