Basic Information
| Provider Information | |||||||||
| NPI: | 1295823185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | LORRIE | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 720 S COLORADO BLVD | ||||||||
| Address2: | SUITE 220A | ||||||||
| City: | GLENDALE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802461912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035848231 | ||||||||
| FaxNumber: | 8662100907 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 E 19TH AVE | ||||||||
| Address2: | SUITE 6600 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038322344 | ||||||||
| FaxNumber: | 3038323721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 19123 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 59931744 | 01 | CO | MEDICAID GROUP NUMBER | OTHER | C809609 | 01 | CO | MEDICARE GROUP NUMBER | OTHER | 01191238 | 05 | CO | MEDICAID | 88150062 | 01 | CO | MEDICAID PRACTICE GROUP # | OTHER |