Provider Demographics
NPI:1619032067
Name:UDOM, DAVID ISONGUYO (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ISONGUYO
Last Name:UDOM
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 1:127 N. OAK AVENUE
Mailing Address - Street 2:SUITE D
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501
Mailing Address - Country:US
Mailing Address - Phone:931-783-5857
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:ONE MEDICAL CENTER BLVD.
Practice Address - Street 2:SUITE 103
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-783-2770
Practice Address - Fax:931-525-1176
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD28832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512299Medicaid
TN3838486Medicaid
TN4107089OtherTNCARE ID NO.
TN1512299Medicaid
TN3838486Medicaid
TN3838489Medicare PIN