Provider Demographics
NPI:1942282389
Name:ODINET, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:ODINET
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 1:200 BEAULLIEU DR
Mailing Address - Street 2:BUILDING 6
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7230
Mailing Address - Country:US
Mailing Address - Phone:337-234-8648
Mailing Address - Fax:337-233-0244
Practice Address - Street 1:200 BEAULLIEU DR
Practice Address - Street 2:BUILDING 6
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7230
Practice Address - Country:US
Practice Address - Phone:337-234-8648
Practice Address - Fax:337-233-0244
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD019937207Y00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1388050Medicaid
LA5J377Medicare ID - Type Unspecified
LA1388050Medicaid