Provider Demographics
NPI:1669661492
Name:TAWADROUS, ODETTE R (MD)
Entity type:Individual
Prefix:MRS
First Name:ODETTE
Middle Name:R
Last Name:TAWADROUS
Suffix:
Gender:F
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:PO BOX 1018
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90702-1018
Mailing Address - Country:US
Mailing Address - Phone:562-841-1602
Mailing Address - Fax:
Practice Address - Street 1:3625 MARTIN LUTHER KING JR BLVD STE 10
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3509
Practice Address - Country:US
Practice Address - Phone:562-841-1602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A991720Medicaid
CADH529AMedicare PIN