Provider Demographics
NPI:1912385527
Name:LODGEN, KELLY REED (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:REED
Last Name:LODGEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3326 FRONT ST STE B
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-6418
Mailing Address - Country:US
Mailing Address - Phone:318-435-7333
Mailing Address - Fax:318-435-9061
Practice Address - Street 1:3326 FRONT ST STE B
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295
Practice Address - Country:US
Practice Address - Phone:318-435-7333
Practice Address - Fax:318-435-9061
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA303772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2390899Medicaid