Provider Demographics
NPI:1356713721
Name:ODUSOLA, JIMMY D
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:D
Last Name:ODUSOLA
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 1:327 COLLEGE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3481
Mailing Address - Country:US
Mailing Address - Phone:916-410-6000
Mailing Address - Fax:530-419-2603
Practice Address - Street 1:327 COLLEGE ST STE 107
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3481
Practice Address - Country:US
Practice Address - Phone:916-410-6000
Practice Address - Fax:530-419-2603
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA6498774343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)