Healthcare Provider Details

I. General information

NPI: 1447409255
Provider Name (Legal Business Name): JOY ODETA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 BUTNER DR
HOPE IN
47246-9447
US

IV. Provider business mailing address

14 TRAFALGAR SQ
TRAFALGAR IN
46181-9515
US

V. Phone/Fax

Practice location:
  • Phone: 812-546-6000
  • Fax:
Mailing address:
  • Phone: 317-739-4895
  • Fax: 317-878-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.205074
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01078300A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: