Provider Demographics
NPI:1093815474
Name:ODOM, CECIL DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:CECIL
Middle Name:DOUGLAS
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 RIVER OAKS DRIVE,
Mailing Address - Street 2:STE 310
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-932-5006
Mailing Address - Fax:601-932-4548
Practice Address - Street 1:1020 RIVER OAKS DRIVE,
Practice Address - Street 2:STE 310
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-932-5006
Practice Address - Fax:601-932-4548
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05821207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017818Medicaid
MS160000689Medicare ID - Type Unspecified
MS00017818Medicaid