Provider Demographics
NPI:1922424688
Name:ODY, JUSTIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:ODY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 PIIKEA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-8268
Mailing Address - Country:US
Mailing Address - Phone:808-874-8100
Mailing Address - Fax:808-874-6887
Practice Address - Street 1:221 PIIKEA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-8268
Practice Address - Country:US
Practice Address - Phone:808-874-8100
Practice Address - Fax:808-874-6887
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-553363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical