Provider Demographics
NPI:1326097338
Name:OTIENO, CHARLES EVAN OMONDI (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EVAN OMONDI
Last Name:OTIENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2034 LOS AMIGOS ST
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1346
Mailing Address - Country:US
Mailing Address - Phone:323-459-7089
Mailing Address - Fax:
Practice Address - Street 1:960 E GREEN ST. THATCHER MEDICAL CENTER
Practice Address - Street 2:SUITE L10
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106
Practice Address - Country:US
Practice Address - Phone:626-486-2674
Practice Address - Fax:626-486-2674
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85874207P00000X
NMMD2006-0790207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA124891Medicare UPIN
CACC398YMedicare PIN