Provider Demographics
NPI:1154614816
Name:ODETI, SHYAM SUNDHAR (MD)
Entity type:Individual
Prefix:
First Name:SHYAM SUNDHAR
Middle Name:
Last Name:ODETI
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 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:FOURTH FLOOR
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7659
Mailing Address - Country:US
Mailing Address - Phone:276-258-4050
Mailing Address - Fax:276-258-4056
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7659
Practice Address - Country:US
Practice Address - Phone:276-258-4050
Practice Address - Fax:276-258-4056
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101256639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1154614816Medicaid
VAP01493724OtherRAILROAD
VAVVE431AMedicare PIN