Basic Information
| Provider Information | |||||||||
| NPI: | 1912183591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODIONU | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10835 NORTH 25TH AVENUE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850293452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027890344 | ||||||||
| FaxNumber: | 6027898729 | ||||||||
| Practice Location | |||||||||
| Address1: | 10835 NORTH 25TH AVENUE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850293452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027890344 | ||||||||
| FaxNumber: | 6027898729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2008 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 40238 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | MD2014-0728 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | Q2038 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 363026 | 05 | AZ | MEDICAID |