Provider Demographics
NPI:1134177645
Name:IDOWU, BENEDICT EKUNDAYO SR (DO)
Entity type:Individual
Prefix:DR
First Name:BENEDICT
Middle Name:EKUNDAYO
Last Name:IDOWU
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:BEN
Other - Middle Name:E
Other - Last Name:IDOWU
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3684 S COTTAGES AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2790
Mailing Address - Country:US
Mailing Address - Phone:504-858-5553
Mailing Address - Fax:225-296-1642
Practice Address - Street 1:3636 S SHERWOOD FOREST BLVD STE 650
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-5216
Practice Address - Country:US
Practice Address - Phone:225-756-2180
Practice Address - Fax:225-756-2179
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0218092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1997561Medicaid
LA5U731Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
LA1997561Medicaid