Provider Demographics
NPI:1851953632
Name:ODISHO, TANYA (DO)
Entity type:Individual
Prefix:MISS
First Name:TANYA
Middle Name:
Last Name:ODISHO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6071 OUTER DR W
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235
Mailing Address - Country:US
Mailing Address - Phone:313-966-4770
Mailing Address - Fax:
Practice Address - Street 1:6071 OUTER DR W
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-966-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program