Provider Demographics
NPI:1174733125
Name:O'DELL, JASON B (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:B
Last Name:O'DELL
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:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7092
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:1005 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2707
Practice Address - Country:US
Practice Address - Phone:843-777-7900
Practice Address - Fax:843-777-7102
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27197207X00000X, 207XX0004X
FLME103720207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00052500Medicaid
FL9234356OtherAETNA
LA21464Medicaid
FL329791OtherAVMED
FL9250826OtherCIGNA
FL23163OtherBCBS
SC271976Medicaid
LA21464Medicaid
FLCA416ZMedicare PIN