Provider Demographics
NPI:1992130405
Name:ODA, NINOS M (MD)
Entity type:Individual
Prefix:
First Name:NINOS
Middle Name:M
Last Name:ODA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 ORANGE TREE LN STE 200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15095 AMARGOSA ROAD
Practice Address - Street 2:BLDG 1 STE 106
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394
Practice Address - Country:US
Practice Address - Phone:760-245-6495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271683207X00000X
IN01076386A207X00000X
MI4301106600207X00000X
CAC161324207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery