Provider Demographics
NPI:1700068855
Name:ODEDRA, NIRMALJI (MD)
Entity Type:Individual
Prefix:
First Name:NIRMALJI
Middle Name:
Last Name:ODEDRA
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 1:3655 W ANTHEM WAY STE A109
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-0430
Mailing Address - Country:US
Mailing Address - Phone:623-505-4479
Mailing Address - Fax:
Practice Address - Street 1:3655 W. ANTHEM WY STE A-109 PMB313
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086
Practice Address - Country:US
Practice Address - Phone:623-505-4479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ81013207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ81013OtherTRAINING PERMIT