Provider Demographics
NPI:1124105945
Name:O'DELL, JOHN TYUS (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:TYUS
Last Name:O'DELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W4523 COUNTY ROAD IW
Mailing Address - Street 2:
Mailing Address - City:WALDO
Mailing Address - State:WI
Mailing Address - Zip Code:53093-1639
Mailing Address - Country:US
Mailing Address - Phone:920-564-6107
Mailing Address - Fax:
Practice Address - Street 1:110 N 9TH ST
Practice Address - Street 2:
Practice Address - City:OOSTBURG
Practice Address - State:WI
Practice Address - Zip Code:53070-1174
Practice Address - Country:US
Practice Address - Phone:920-564-3699
Practice Address - Fax:920-564-3605
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5421-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0007431405OtherAETNA
WI40314400Medicaid
WI000285005Medicare ID - Type Unspecified
WI40314400Medicaid