Provider Demographics
NPI:1356437040
Name:ODERINDE, JULIUS B (MD )
Entity type:Individual
Prefix:
First Name:JULIUS
Middle Name:B
Last Name:ODERINDE
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 1:5403 SANDY LK E
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3944
Mailing Address - Country:US
Mailing Address - Phone:478-714-6901
Mailing Address - Fax:
Practice Address - Street 1:5403 SANDY LK E
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-3944
Practice Address - Country:US
Practice Address - Phone:478-714-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036658207PE0004X
GA36658207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF69487Medicaid
GA08BDMHWMedicare PIN