Provider Demographics
NPI:1063282069
Name:O'DELL-KORN, JAMES WENDELL
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WENDELL
Last Name:O'DELL-KORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1251
Mailing Address - Country:US
Mailing Address - Phone:315-755-1251
Mailing Address - Fax:
Practice Address - Street 1:650 STATE STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1251
Practice Address - Country:US
Practice Address - Phone:315-755-1251
Practice Address - Fax:315-291-6601
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator