Basic Information
| Provider Information | |||||||||
| NPI: | 1679994123 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALICIA J. ODUM, MD PA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8484 | ||||||||
| Address2: | |||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208988484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023161726 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1625 PICCARD DR | ||||||||
| Address2: | UNIT 402 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208507600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023161726 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/01/2014 | ||||||||
| LastUpdateDate: | 01/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | ODUM | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 2023161726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | DO60844 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1457363517 | 01 | MD | INDIVIDUAL NPI | OTHER |