Provider Demographics
NPI:1912183591
Name:ODIONU, ANDREW K (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:K
Last Name:ODIONU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10835 NORTH 25TH AVENUE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3452
Mailing Address - Country:US
Mailing Address - Phone:602-789-0344
Mailing Address - Fax:602-789-8729
Practice Address - Street 1:10835 NORTH 25TH AVENUE
Practice Address - Street 2:SUITE 115
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-3452
Practice Address - Country:US
Practice Address - Phone:602-789-0344
Practice Address - Fax:602-789-8729
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ40238207R00000X
NMMD2014-0728208000000X
TXQ2038208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ363026Medicaid
AZ363026Medicaid