Provider Demographics
NPI:1003846809
Name:ODOM, LEANDRE W (DO)
Entity Type:Individual
Prefix:DR
First Name:LEANDRE
Middle Name:W
Last Name:ODOM
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Gender:M
Credentials:DO
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Mailing Address - Street 1:2313 E MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-4091
Mailing Address - Country:US
Mailing Address - Phone:337-560-5323
Mailing Address - Fax:337-560-4666
Practice Address - Street 1:2313 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4091
Practice Address - Country:US
Practice Address - Phone:337-560-5323
Practice Address - Fax:337-560-4666
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2010-07-06
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Provider Licenses
StateLicense IDTaxonomies
LA025417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1576271Medicaid
LAH47682Medicare UPIN
LA1576271Medicaid