Provider Demographics
NPI:1457447443
Name:ODEH, YASEEN K (MD)
Entity Type:Individual
Prefix:
First Name:YASEEN
Middle Name:K
Last Name:ODEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5236
Mailing Address - Country:US
Mailing Address - Phone:312-432-1707
Mailing Address - Fax:312-432-0806
Practice Address - Street 1:1544 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5236
Practice Address - Country:US
Practice Address - Phone:312-432-1707
Practice Address - Fax:312-432-0806
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF44960Medicare UPIN