Provider Demographics
NPI:1689627176
Name:ODOGWU, LAURETTA IFEOMA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURETTA
Middle Name:IFEOMA
Last Name:ODOGWU
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 1:3800 RESERVOIR RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2113
Mailing Address - Country:US
Mailing Address - Phone:202-444-3976
Mailing Address - Fax:
Practice Address - Street 1:3800 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007
Practice Address - Country:US
Practice Address - Phone:202-444-3976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300511207R00000X, 207RX0202X
DCMD31679207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1346AOtherBCBS NC
NC3953934OtherAETNA
NC803556OtherPARTNERS MEDICARE
NCE3248OtherMEDCOST
NC891346AMedicaid
NC3953934OtherAETNA
NC803556OtherPARTNERS MEDICARE