Provider Demographics
NPI:1538351200
Name:ODEN, GLENDA D (RD, CDE, LDN)
Entity type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:D
Last Name:ODEN
Suffix:
Gender:F
Credentials:RD, CDE, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4259 S BERKELEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3030
Mailing Address - Country:US
Mailing Address - Phone:773-268-7600
Mailing Address - Fax:773-268-1480
Practice Address - Street 1:4259 S BERKELEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3030
Practice Address - Country:US
Practice Address - Phone:773-268-7600
Practice Address - Fax:773-268-1480
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000664133VN1006X
MSD1416133VN1006X
IL164.009143133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I503616Medicare PIN