Provider Demographics
NPI:1578279667
Name:ANDRADE AGUIAR, ODMIR (PHD, SPP, A-ET)
Entity Type:Individual
Prefix:
First Name:ODMIR
Middle Name:
Last Name:ANDRADE AGUIAR
Suffix:
Gender:M
Credentials:PHD, SPP, A-ET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 KENTWORTH LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-3251
Mailing Address - Country:US
Mailing Address - Phone:404-502-8599
Mailing Address - Fax:
Practice Address - Street 1:4555 MANSELL RD STE 300
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-8219
Practice Address - Country:US
Practice Address - Phone:404-502-8599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ2176058174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist