Provider Demographics
NPI:1639134588
Name:UDOM, IZUKA P (MD)
Entity Type:Individual
Prefix:DR
First Name:IZUKA
Middle Name:P
Last Name:UDOM
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 1:8515 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1879
Mailing Address - Country:US
Mailing Address - Phone:516-459-3329
Mailing Address - Fax:718-978-6888
Practice Address - Street 1:11811 GUY R BREWER BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434
Practice Address - Country:US
Practice Address - Phone:718-945-7150
Practice Address - Fax:718-978-6888
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169783207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01023505Medicaid
B20273Medicare UPIN
NY01023505Medicaid
NY0105IEMedicare ID - Type Unspecified