Provider Demographics
NPI:1811927361
Name:ODEGAARD, RITA VIDA (MD)
Entity type:Individual
Prefix:DR
First Name:RITA
Middle Name:VIDA
Last Name:ODEGAARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RITA
Other - Middle Name:JOY
Other - Last Name:VIDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3756 KING WILLIAMS CT
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-7806
Mailing Address - Country:US
Mailing Address - Phone:630-762-8834
Mailing Address - Fax:
Practice Address - Street 1:2160 SOUTH FIRST AVENUE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0898152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL62699OtherPIN
ILL62699OtherPIN