Provider Demographics
NPI:1902984834
Name:ODLE, JOHN SCOT (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOT
Last Name:ODLE
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 1:1800 BIRMINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-5461
Mailing Address - Country:US
Mailing Address - Phone:205-384-4474
Mailing Address - Fax:205-384-4428
Practice Address - Street 1:1800 BIRMINGHAM AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-5461
Practice Address - Country:US
Practice Address - Phone:205-384-4474
Practice Address - Fax:205-384-4428
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL462213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL76296OtherBC/BS
AL480034067OtherRAILROAD MEDICARE
AL157OtherALABAMA LICENSE #
AL1181700001Medicare NSC
AL76296OtherBC/BS