Provider Demographics
NPI:1407827108
Name:ODOM, CHARLES A (CRNA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:ODOM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8511 MCPHERSON ROAD
Mailing Address - Street 2:SUITE 105, PMB 233
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045
Mailing Address - Country:US
Mailing Address - Phone:956-523-2619
Mailing Address - Fax:
Practice Address - Street 1:10700 MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-6268
Practice Address - Country:US
Practice Address - Phone:956-523-2619
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221707367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84078UOtherBCBS
TXP00129710OtherMEDICARE RAILROAD
TX8B7494Medicare ID - Type Unspecified