1255313813 NPI number — CHRISTINE A ODELL MD, MPH

Table of content: CHRISTINE A ODELL MD, MPH (NPI 1255313813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255313813 NPI number — CHRISTINE A ODELL MD, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODELL
Provider First Name:
CHRISTINE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, MPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LICHTOR
Provider Other First Name:
CHRISTINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255313813
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 SARGENT DR
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06511-6100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-781-4321
Provider Business Mailing Address Fax Number:
203-781-4329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 SARGENT DR
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06511-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-781-4321
Provider Business Practice Location Address Fax Number:
203-781-4329
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  053435 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2037696 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: C06778 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 008055097 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: C09463 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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