Healthcare Provider Details

I. General information

NPI: 1245641240
Provider Name (Legal Business Name): JOHN EZE ODOME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 4TH ST N STE 300
ST PETERSBURG FL
33702-4399
US

IV. Provider business mailing address

1111 6TH AVE
DES MOINES IA
50314-2613
US

V. Phone/Fax

Practice location:
  • Phone: 727-513-9060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD-43501
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberME123608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: