Provider Demographics
NPI:1861539488
Name:ODERKIRK, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ODERKIRK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 HENDERSON AVE
Mailing Address - Street 2:BLDG 310
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92140
Mailing Address - Country:US
Mailing Address - Phone:619-524-8673
Mailing Address - Fax:
Practice Address - Street 1:1650 HENDERSON AVE
Practice Address - Street 2:BLDG 310
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140
Practice Address - Country:US
Practice Address - Phone:619-524-8673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1662309146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic