Healthcare Provider Details

I. General information

NPI: 1790146629
Provider Name (Legal Business Name): MICHAEL ODANIEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2016
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 RANDALLIA DR
FORT WAYNE IN
46805-4638
US

IV. Provider business mailing address

608 UNION CHAPEL RD
FORT WAYNE IN
46845-9357
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-4000
  • Fax:
Mailing address:
  • Phone: 260-498-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02005977
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: