Provider Demographics
NPI:1780780528
Name:ODUDU, ISAAC A (MD)
Entity type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:A
Last Name:ODUDU
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 1:208 RIDGEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3320
Mailing Address - Country:US
Mailing Address - Phone:318-483-6571
Mailing Address - Fax:
Practice Address - Street 1:639 LOTUS DR N
Practice Address - Street 2:SUITE B
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-2926
Practice Address - Country:US
Practice Address - Phone:985-626-6133
Practice Address - Fax:985-626-6136
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13224R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1558346Medicaid
LA5E710DF59Medicare PIN
LA5E710Medicare ID - Type Unspecified
LA1558346Medicaid