Provider Demographics
NPI:1538133210
Name:IZE-IYAMU, MENONI (MD)
Entity Type:Individual
Prefix:
First Name:MENONI
Middle Name:
Last Name:IZE-IYAMU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MENONI
Other - Middle Name:
Other - Last Name:IZE-IYAMU
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:407 CINCINNATI ST
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:LA
Mailing Address - Zip Code:71232-3007
Mailing Address - Country:US
Mailing Address - Phone:318-878-5171
Mailing Address - Fax:318-878-8638
Practice Address - Street 1:407 CINCINNATI ST
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:LA
Practice Address - Zip Code:71232-3007
Practice Address - Country:US
Practice Address - Phone:318-878-5171
Practice Address - Fax:318-878-8638
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA023122OtherLICENSE
LA1494682Medicaid
G64533Medicare UPIN
LA023122OtherLICENSE