Healthcare Provider Details

I. General information

NPI: 1770143539
Provider Name (Legal Business Name): TARIQ YOUSEF ELIAS ODEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CAMBRIGE ST
KANSAS CITY KS
66160-0001
US

IV. Provider business mailing address

743 SPRING ST NE
GAINESVILLE GA
30501-3899
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-1227
  • Fax:
Mailing address:
  • Phone: 770-219-8734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number04-51901
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-51901
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: