Provider Demographics
NPI:1659432193
Name:UDOFA, ANIEDI ETUKUDO FRED (MD)
Entity Type:Individual
Prefix:
First Name:ANIEDI
Middle Name:ETUKUDO FRED
Last Name:UDOFA
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 1:3843 HARDING BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70807-5224
Mailing Address - Country:US
Mailing Address - Phone:225-953-9315
Mailing Address - Fax:225-359-9326
Practice Address - Street 1:3843 HARDING BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-5224
Practice Address - Country:US
Practice Address - Phone:225-953-9315
Practice Address - Fax:225-359-9326
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14261R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1572101Medicaid
LA4E512Medicare ID - Type Unspecified
LA1572101Medicaid