Provider Demographics
NPI:1588696298
Name:OMOHUNDRO, JOHN R (ATC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:OMOHUNDRO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8701 S HARDY DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-2800
Mailing Address - Country:US
Mailing Address - Phone:602-379-0101
Mailing Address - Fax:480-467-1952
Practice Address - Street 1:8701 S HARDY DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2800
Practice Address - Country:US
Practice Address - Phone:602-379-0101
Practice Address - Fax:480-467-1952
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0087173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine