Provider Demographics
NPI:1285963082
Name:ODJEGBA, ISAIAH M (RN)
Entity type:Individual
Prefix:MR
First Name:ISAIAH
Middle Name:M
Last Name:ODJEGBA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 N VINE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-1612
Mailing Address - Country:US
Mailing Address - Phone:323-769-6101
Mailing Address - Fax:
Practice Address - Street 1:1224 N VINE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1612
Practice Address - Country:US
Practice Address - Phone:323-769-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA735312163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse