MEDICARE: MR. ANTONY OTIENO ODHIAMBO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0351067668254	OTHER	MD	DRIVE'S LICENSE NO

General Provider Information

NPI Number	:	1720506025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTONY OTIENO ODHIAMBO

Provider Business Mailing Address
First Line	:	1606 UNIVERSITY BLVD W
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-3649
Country	:	US
Telephone Number	:	240-815-3480
Fax Number	:

Provider Business Practice Location Address
First Line	:	1606 UNIVERSITY BLVD W
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-3649
Country	:	US
Telephone Number	:	240-815-3480
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2017
Last Update Date	:	02/04/2026

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