Provider Demographics
NPI:1093713810
Name:MCLEOD, EDNA WISE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDNA
Middle Name:WISE
Last Name:MCLEOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71458-0207
Mailing Address - Country:US
Mailing Address - Phone:318-352-3492
Mailing Address - Fax:318-352-3524
Practice Address - Street 1:501 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6018
Practice Address - Country:US
Practice Address - Phone:318-214-4274
Practice Address - Fax:318-214-4275
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0099442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1323748Medicaid
LA1323748Medicaid
B89062Medicare UPIN
LA5K454DE51Medicare PIN