Provider Demographics
NPI:1427144971
Name:ODA, MARJORIE Y (MD)
Entity type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:Y
Last Name:ODA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:611 LA MESA DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028
Mailing Address - Country:US
Mailing Address - Phone:650-854-2831
Mailing Address - Fax:415-922-6344
Practice Address - Street 1:1 DANIEL BURNHAM COURT
Practice Address - Street 2:SUITE 365C
Practice Address - City:SAN FRANCSICO
Practice Address - State:CA
Practice Address - Zip Code:94109
Practice Address - Country:US
Practice Address - Phone:415-202-1920
Practice Address - Fax:415-922-6344
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30402173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA913552OtherQME CERTIFICATE
CAG30402OtherCA LICENSE
CAA07012191OtherDEA CERTIFICATE
CA913552OtherQME CERTIFICATE