Provider Demographics
NPI:1215953732
Name:ODOM, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6390 PLEASANT VIEW CV
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9263
Mailing Address - Country:US
Mailing Address - Phone:952-906-2011
Mailing Address - Fax:
Practice Address - Street 1:6545 FLYING CLOUD DR STE 201
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3356
Practice Address - Country:US
Practice Address - Phone:952-224-1919
Practice Address - Fax:763-710-8154
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN44235207P00000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH56035Medicare UPIN