Provider Demographics
NPI:1316939424
Name:ODRO, MARVIN (DPM)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:ODRO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4046
Mailing Address - Country:US
Mailing Address - Phone:863-687-3404
Mailing Address - Fax:863-687-4672
Practice Address - Street 1:2939 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4046
Practice Address - Country:US
Practice Address - Phone:863-687-3404
Practice Address - Fax:863-687-4672
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 0000788213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87321Medicare ID - Type Unspecified
T55417Medicare UPIN