Provider Demographics
NPI:1124126115
Name:CHARLES A ODOM PC
Entity type:Organization
Organization Name:CHARLES A ODOM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:956-725-4003
Mailing Address - Street 1:5313 MCPHERSON RD
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041
Mailing Address - Country:US
Mailing Address - Phone:956-795-8310
Mailing Address - Fax:956-795-8313
Practice Address - Street 1:5313 MCPHERSON RD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041
Practice Address - Country:US
Practice Address - Phone:956-725-4003
Practice Address - Fax:956-725-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221707367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C85SOtherBCBS
R69948Medicare UPIN
TX00932YMedicare ID - Type Unspecified