Provider Demographics
NPI:1740254184
Name:ODUKOMAIYA, HENRY A (MD)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:A
Last Name:ODUKOMAIYA
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:PO BOX 47535
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33646-0113
Mailing Address - Country:US
Mailing Address - Phone:813-755-0006
Mailing Address - Fax:813-986-2731
Practice Address - Street 1:5331 PRIMROSE LAKE CIR STE 112
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3764
Practice Address - Country:US
Practice Address - Phone:813-651-1085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024433500Medicaid
G25475Medicare UPIN
FL27388UMedicare PIN