Provider Demographics
NPI:1437327905
Name:CRISP-COLEMAN, KODI FAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KODI
Middle Name:FAY
Last Name:CRISP-COLEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:9001 SUMMA AVENUE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAGETP.EBR.FP207Q00000X
LAMD.204059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08077518Medicaid
LAGETP.EBR.FPOtherTEMPORARY LICENSE NUMBER
LA1000281Medicaid
MS08077518Medicaid