Provider Demographics
NPI:1144274234
Name:ODOM, LEROY (MD)
Entity type:Individual
Prefix:DR
First Name:LEROY
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 CRAWFORD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-9014
Mailing Address - Country:US
Mailing Address - Phone:713-658-8660
Mailing Address - Fax:713-658-0205
Practice Address - Street 1:2101 CRAWFORD ST STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8941
Practice Address - Country:US
Practice Address - Phone:713-658-8660
Practice Address - Fax:713-658-0205
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-21
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6295207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099388302Medicaid
TXPK63Medicare PIN
TX099388302Medicaid