Provider Demographics
NPI:1003220138
Name:O'DELL, JUSTINE J (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:J
Last Name:O'DELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:532 HAYWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607
Mailing Address - Country:US
Mailing Address - Phone:864-288-7445
Mailing Address - Fax:864-288-8288
Practice Address - Street 1:532 HAYWOOD ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607
Practice Address - Country:US
Practice Address - Phone:864-288-7445
Practice Address - Fax:864-288-8288
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1823152WL0500X, 152WV0400X, 152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD18238Medicaid