Provider Demographics
NPI:1174304828
Name:ODUM, JOSHUA TAYLOR (DPT)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:TAYLOR
Last Name:ODUM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 POSEY ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6347
Mailing Address - Country:US
Mailing Address - Phone:618-889-4973
Mailing Address - Fax:
Practice Address - Street 1:3116 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5212
Practice Address - Country:US
Practice Address - Phone:618-993-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070027222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist