Healthcare Provider Details

I. General information

NPI: 1427560804
Provider Name (Legal Business Name): LISA ODENDAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA ODENDAL MD

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701
US

IV. Provider business mailing address

15 DISCOVERY RIDGE LANE SW
CALGARY AB
T3H 4Y3
CA

V. Phone/Fax

Practice location:
  • Phone: 727-767-3051
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number133859
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: