Provider Demographics
NPI:1841251790
Name:ODOM, RICHARD D (DPM)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:ODOM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 CLAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4004
Mailing Address - Country:US
Mailing Address - Phone:404-321-6111
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX812213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86J274OtherBLUE SHIELD
TX480030644OtherRR/MEDICARE
TX1215584-01OtherCSHCN
TX1215584-02Medicaid
TXT15089Medicare UPIN
TX86J274Medicare ID - Type Unspecified