1326097338 NPI number — DR. CHARLES EVAN OMONDI OTIENO M.D.

Table of content: DR. CHARLES EVAN OMONDI OTIENO M.D. (NPI 1326097338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326097338 NPI number — DR. CHARLES EVAN OMONDI OTIENO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTIENO
Provider First Name:
CHARLES
Provider Middle Name:
EVAN OMONDI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326097338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2034 LOS AMIGOS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA CANADA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91011-1346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-459-7089
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
960 E GREEN ST. THATCHER MEDICAL CENTER
Provider Second Line Business Practice Location Address:
SUITE L10
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-486-2674
Provider Business Practice Location Address Fax Number:
626-486-2674
Provider Enumeration Date:
05/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  A85874 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: MD2006-0790 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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