Basic Information
Provider Information | |||||||||
NPI: | 1659315737 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ODDIS | ||||||||
FirstName: | CARMINE | ||||||||
MiddleName: | V | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 682 HEMLOCK ST | ||||||||
Address2: | SUITE 490 | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312018307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787411208 | ||||||||
FaxNumber: | 4787411557 | ||||||||
Practice Location | |||||||||
Address1: | 682 HEMLOCK ST | ||||||||
Address2: | SUITE 490 | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312018307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787411208 | ||||||||
FaxNumber: | 4787411557 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 51072 | GA | X |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 51072 | GA | X |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 2085N0904X | 51072 | GA | X |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
No ID Information.