Provider Demographics
NPI:1164742268
Name:AJISE, ALFRED GODWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:GODWIN
Last Name:AJISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:90 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5926
Mailing Address - Country:US
Mailing Address - Phone:318-238-3820
Mailing Address - Fax:318-238-3823
Practice Address - Street 1:90 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5926
Practice Address - Country:US
Practice Address - Phone:318-238-3820
Practice Address - Fax:318-238-3823
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA324090207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2538501Medicaid