Provider Demographics
NPI:1366438244
Name:SIJIN, ODALIS (MD)
Entity type:Individual
Prefix:
First Name:ODALIS
Middle Name:
Last Name:SIJIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ODALIS
Other - Middle Name:
Other - Last Name:SIJIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 TAMPA GENERAL CIR FL STC4
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3603
Practice Address - Country:US
Practice Address - Phone:813-259-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59075207V00000X
MS18497207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIO0X8OtherBLUE CROSS AND BLUE SHIELD
FL019116900Medicaid
MS4200070OtherAETNA
FL019116900Medicaid
MS4200070OtherAETNA
MSP00217322Medicare PIN
FLIO0X8OtherBLUE CROSS AND BLUE SHIELD
MS160000644Medicare PIN