Provider Demographics
NPI:1417167313
Name:ODERO, RANDY O (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:O
Last Name:ODERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7000 N 16TH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5524
Mailing Address - Country:US
Mailing Address - Phone:405-796-8367
Mailing Address - Fax:602-428-6999
Practice Address - Street 1:1930 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7711
Practice Address - Country:US
Practice Address - Phone:602-532-1700
Practice Address - Fax:602-532-1701
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41308207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ438170Medicaid
AZ41308OtherLICENSE