Provider Demographics
NPI:1245695477
Name:ODEDE, ENOS
Entity type:Individual
Prefix:
First Name:ENOS
Middle Name:
Last Name:ODEDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3773 TIMBERGLEN RD APT 805
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-3719
Mailing Address - Country:US
Mailing Address - Phone:214-862-2951
Mailing Address - Fax:
Practice Address - Street 1:3773 TIMBERGLEN RD APT 805
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-3719
Practice Address - Country:US
Practice Address - Phone:214-862-2951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX777392163W00000X, 163WG0000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163W00000XNursing Service ProvidersRegistered Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide