Provider Demographics
NPI:1609868058
Name:STILL, ODELL P (DO)
Entity type:Individual
Prefix:
First Name:ODELL
Middle Name:P
Last Name:STILL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1297
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-7297
Mailing Address - Country:US
Mailing Address - Phone:478-783-0299
Mailing Address - Fax:478-783-3730
Practice Address - Street 1:136 W DYKES ST
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014
Practice Address - Country:US
Practice Address - Phone:478-934-0030
Practice Address - Fax:478-783-3730
Is Sole Proprietor?:No
Enumeration Date:2005-08-20
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA37085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000539624OMedicaid
GAGRP3252Medicare ID - Type UnspecifiedMEDICARE #
GA000539624OMedicaid
GA000539624CMedicaid
GA000539624BMedicaid
GAGRP3252Medicare ID - Type UnspecifiedMEDICARE #