Provider Demographics
NPI:1043808165
Name:ODIZ, SIVAN
Entity type:Individual
Prefix:
First Name:SIVAN
Middle Name:
Last Name:ODIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5603 NW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3107
Mailing Address - Country:US
Mailing Address - Phone:954-867-6490
Mailing Address - Fax:
Practice Address - Street 1:401 NW 42ND AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2835
Practice Address - Country:US
Practice Address - Phone:954-587-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9116792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program