Provider Demographics
NPI:1699569269
Name:ODOM, SASHA M
Entity type:Individual
Prefix:
First Name:SASHA
Middle Name:M
Last Name:ODOM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2426 55TH PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3502
Mailing Address - Country:US
Mailing Address - Phone:463-221-2605
Mailing Address - Fax:463-221-2507
Practice Address - Street 1:2426 55TH PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3502
Practice Address - Country:US
Practice Address - Phone:463-221-2605
Practice Address - Fax:463-221-2507
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN247200000X, 247ZC0005X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Multi-Specialty
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty