Provider Demographics
NPI:1336331891
Name:ODONWODO, EBELE C (MD)
Entity Type:Individual
Prefix:
First Name:EBELE
Middle Name:C
Last Name:ODONWODO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8438 BRADFORD PEAR DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-7434
Mailing Address - Country:US
Mailing Address - Phone:585-260-9944
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:SUITE A721
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-3139
Practice Address - Fax:616-391-3044
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097441207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336331891Medicaid
MI1417961137OtherBCBSM - BMH
MI1417961137OtherBCBSM - BMH
MI0M74460374Medicare PIN
D16150259Medicare PIN