Provider Demographics
NPI:1639638844
Name:KUKU, AYOTUNDE (MD)
Entity Type:Individual
Prefix:
First Name:AYOTUNDE
Middle Name:
Last Name:KUKU
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:PO BOX 33932
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-3932
Mailing Address - Country:US
Mailing Address - Phone:318-626-2326
Mailing Address - Fax:318-626-3892
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-2326
Practice Address - Fax:318-626-3892
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA327948207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program