Provider Demographics
NPI:1679524375
Name:UDO, ANTHONIA
Entity Type:Individual
Prefix:MS
First Name:ANTHONIA
Middle Name:
Last Name:UDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3403
Mailing Address - Country:US
Mailing Address - Phone:213-389-7491
Mailing Address - Fax:213-389-6218
Practice Address - Street 1:4055 WILSHIRE BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3403
Practice Address - Country:US
Practice Address - Phone:213-389-7491
Practice Address - Fax:213-389-6218
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA332B00000XMedicare NSC