Basic Information
| Provider Information | |||||||||
| NPI: | 1992130405 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ODA | ||||||||
| FirstName: | NINOS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 ORANGE TREE LN STE 200 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923744587 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15095 AMARGOSA ROAD | ||||||||
| Address2: | BLDG 1 STE 106 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602456495 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2013 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 271683 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 01076386A | IN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 4301106600 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | C161324 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.