Provider Demographics
NPI:1437328465
Name:ODERMAN, LAETITIA MARIE-JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAETITIA
Middle Name:MARIE-JANE
Last Name:ODERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAETITIA
Other - Middle Name:MARIE-JANE
Other - Last Name:POISSON DE SOUZY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2025 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1323
Mailing Address - Country:US
Mailing Address - Phone:831-477-2375
Mailing Address - Fax:
Practice Address - Street 1:2907 CHANTICLEER AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1815
Practice Address - Country:US
Practice Address - Phone:831-477-2325
Practice Address - Fax:831-477-2330
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102824207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
EH516ZMedicare PIN
CARES000Medicare UPIN