Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VE0102X | Reproductive Endocrinologist | R7E33 | MO |
NPI | 1336165554 |
---|---|
Provider Name | Dr. Randall R Odem |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63108-2212 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2006 |
Last Update Date | 27/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
202236402 | (05) | MO |
ENROLLED | (05) | IL |