Basic Information
| Provider Information | |||||||||
| NPI: | 1396343695 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ODDIS | ||||||||
| FirstName: | JORDAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4019 CHURCH ST | ||||||||
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| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440946205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404773081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7590 AUBURN RD | ||||||||
| Address2: | |||||||||
| City: | CONCORD TWP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440779176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403758100 | ||||||||
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| ProviderEnumerationDate: | 10/09/2020 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 50.006652RX | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.