Provider Demographics
NPI:1396770566
Name:TAMAKLOE, MARTINA ABENA (MD)
Entity type:Individual
Prefix:DR
First Name:MARTINA
Middle Name:ABENA
Last Name:TAMAKLOE
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 1:327 JEFFERSON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-7080
Mailing Address - Country:US
Mailing Address - Phone:318-254-3001
Mailing Address - Fax:318-254-2962
Practice Address - Street 1:401 E VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5950
Practice Address - Country:US
Practice Address - Phone:318-254-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-11439207R00000X
LA35190207R00000X
LAMD.201853207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1331767Medicaid
LA1331767Medicaid
LA4N0217387Medicare Oscar/Certification