Provider Demographics
NPI:1710402698
Name:ODO, ETHELBERT ONUEFI (NP-C)
Entity Type:Individual
Prefix:MR
First Name:ETHELBERT
Middle Name:ONUEFI
Last Name:ODO
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 PONDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-6219
Mailing Address - Country:US
Mailing Address - Phone:469-556-1467
Mailing Address - Fax:
Practice Address - Street 1:606 ORIOLE BLVD STE 301
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-3500
Practice Address - Country:US
Practice Address - Phone:469-556-1467
Practice Address - Fax:972-296-2001
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134842363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology