Provider Demographics
NPI:1073508016
Name:KODER, BRETT A (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:A
Last Name:KODER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7847 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5505
Mailing Address - Country:US
Mailing Address - Phone:318-212-3960
Mailing Address - Fax:318-212-3907
Practice Address - Street 1:7847 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5505
Practice Address - Country:US
Practice Address - Phone:318-212-3960
Practice Address - Fax:318-212-3907
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.017292207Y00000X
NC96-00594174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343004OtherCOVENTRY HEALTHCARE
NC1041160OtherUNITED HEALTHCARE
NC15359OtherPARTNERS HEALTHPLAN
LA269370YNUVOtherMEDICARE PTAN
LA1974677Medicaid
NC8950035Medicaid
NC2567929006OtherCIGNA HEALTHCARE
NC2103801OtherMAMSI
SC120247Medicaid
NC163923OtherMIDSOUTH INS
NC2019474OtherAETNA HEALTHPLAN
NC040011888OtherRAILROAD MEDICARE
NC50035OtherBLUE CROSS BLUE SHIELD
NC73986OtherMEDCOST
SC120247Medicaid
LA269370YNUVOtherMEDICARE PTAN