Provider Demographics
NPI:1417787540
Name:ODIASE, ITOHAN U
Entity type:Individual
Prefix:
First Name:ITOHAN
Middle Name:U
Last Name:ODIASE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 MLK JR AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-1573
Mailing Address - Country:US
Mailing Address - Phone:240-230-2731
Mailing Address - Fax:
Practice Address - Street 1:3109 MLK JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1573
Practice Address - Country:US
Practice Address - Phone:224-446-6062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X, 171M00000X
DCHHA200004661374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty