Provider Demographics
NPI:1831142355
Name:SAMUDIA, RICARDO (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:SAMUDIA
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:PO BOX 122108
Mailing Address - Street 2:DEPT 2108
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2108
Mailing Address - Country:US
Mailing Address - Phone:337-494-2919
Mailing Address - Fax:337-494-3069
Practice Address - Street 1:1717 OAK PARK BLVD FL 3
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-475-8100
Practice Address - Fax:337-475-8510
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07963R207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E02174Medicare UPIN
55563Medicare ID - Type Unspecified