Provider Demographics
NPI:1073601415
Name:ODLE, LEO (DO)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:ODLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 E BOSTON ST
Mailing Address - Street 2:STE. 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6219
Mailing Address - Country:US
Mailing Address - Phone:480-899-4420
Mailing Address - Fax:480-219-3214
Practice Address - Street 1:3420 S MERCY RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0420
Practice Address - Country:US
Practice Address - Phone:480-899-4420
Practice Address - Fax:480-219-3214
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3357207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ465618Medicaid
H02791Medicare UPIN
AZ465618Medicaid