1740386044 NPI number — DR. LEONA ODEMENA DPM

Table of content: DR. LEONA ODEMENA DPM (NPI 1740386044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740386044 NPI number — DR. LEONA ODEMENA DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODEMENA
Provider First Name:
LEONA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

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:
1740386044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 BRAMBLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21613-2471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-225-6640
Provider Business Mailing Address Fax Number:
443-225-6641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BRAMBLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21613-2471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-225-6640
Provider Business Practice Location Address Fax Number:
443-225-6641
Provider Enumeration Date:
09/15/2006

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: 213E00000X , with the licence number:  01443 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5849300001 . This is a "DURABLE MEDICAL EQUIPMENT (DME) PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 172837 . This is a "MEDICARE TPAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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