Provider Demographics
NPI:1407130925
Name:ODYSSEY INFUSIONS
Entity Type:Organization
Organization Name:ODYSSEY INFUSIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:S
Authorized Official - Last Name:OOMMEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-907-6337
Mailing Address - Street 1:4022 E PRESIDIO ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1113
Mailing Address - Country:US
Mailing Address - Phone:480-985-1093
Mailing Address - Fax:480-296-7643
Practice Address - Street 1:1600 W CHANDLER BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6153
Practice Address - Country:US
Practice Address - Phone:480-907-6337
Practice Address - Fax:480-621-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty