Provider Demographics
NPI:1194788398
Name:ODONG, FRIDAY A
Entity type:Individual
Prefix:MR
First Name:FRIDAY
Middle Name:A
Last Name:ODONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 STOCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-3823
Mailing Address - Country:US
Mailing Address - Phone:702-457-0624
Mailing Address - Fax:702-310-4653
Practice Address - Street 1:4015 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1612
Practice Address - Country:US
Practice Address - Phone:702-457-0624
Practice Address - Fax:702-310-4653
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVH13-00216-6-108724171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV4702810001Medicare ID - Type Unspecified