Provider Demographics
NPI:1720177488
Name:ODURO, WILLIAM NTIAMOAH (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:NTIAMOAH
Last Name:ODURO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:601-A PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8720
Mailing Address - Country:US
Mailing Address - Phone:770-338-8331
Mailing Address - Fax:770-338-9499
Practice Address - Street 1:601-A PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 290
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8720
Practice Address - Country:US
Practice Address - Phone:770-338-8331
Practice Address - Fax:770-338-9499
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52215207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA621555898AMedicaid
16BBCGVMedicare ID - Type Unspecified
GA621555898AMedicaid