Healthcare Provider Details

I. General information

NPI: 1104491752
Provider Name (Legal Business Name): GABRIELLA ODUDU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18601 VALLEY BLVD
BLOOMINGTON CA
92316-1831
US

IV. Provider business mailing address

26384 FOWLER DR
LOMA LINDA CA
92354-6579
US

V. Phone/Fax

Practice location:
  • Phone: 909-546-7560
  • Fax:
Mailing address:
  • Phone: 323-552-3487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA196863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: