Individual
CAROL M ODEGAARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
261 BROOKWOOD AVE, JACKSON, GA 30233-1460
(678) 752-0555
(678) 752-0556
Mailing address
261 BROOKWOOD AVE, JACKSON, GA 30233-1460
(678) 752-0555
(678) 752-0556
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
40495
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000752166S
—
GA
01
—
000752166U
CMOMDPC IND MCAID #
GA
01
—
202I083605
CMOMDPC IND MCARE #
GA
01
—
P00708556
RAILROAD MEDICARE
GA
Enumeration date
10/24/2005
Last updated
05/07/2019
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