Provider Demographics
NPI:1023096237
Name:ODITT, BRYAN KEITH (APA-C)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:KEITH
Last Name:ODITT
Suffix:
Gender:M
Credentials:APA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MOHEGAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-8100
Mailing Address - Country:US
Mailing Address - Phone:860-444-8207
Mailing Address - Fax:860-444-8413
Practice Address - Street 1:15 MOHEGAN AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-8100
Practice Address - Country:US
Practice Address - Phone:860-444-8207
Practice Address - Fax:860-444-8413
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11519363A00000X
CT001247363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant