Basic Information
| Provider Information | |||||||||
| NPI: | 1205245552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601791 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522159119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3474 ROBINHOOD RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271064702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367749977 | ||||||||
| FaxNumber: | 3367186798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2014 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | P15041 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.