Provider Demographics
NPI:1386880318
Name:HENRY A ODUKOMAIYA MD PA
Entity type:Organization
Organization Name:HENRY A ODUKOMAIYA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ODUKOMAIYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-971-5800
Mailing Address - Street 1:3228 COVE BEND DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2752
Mailing Address - Country:US
Mailing Address - Phone:813-971-5800
Mailing Address - Fax:
Practice Address - Street 1:3228 COVE BEND DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2752
Practice Address - Country:US
Practice Address - Phone:813-971-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68789207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty