Provider Demographics
NPI:1952341059
Name:GODEAUX, KENNETH BRYANT (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRYANT
Last Name:GODEAUX
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 1:155 ULYSSE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506
Mailing Address - Country:US
Mailing Address - Phone:337-993-2404
Mailing Address - Fax:
Practice Address - Street 1:155 ULYSSE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506
Practice Address - Country:US
Practice Address - Phone:337-993-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025779207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1048917Medicaid
LA4F461CP22Medicare ID - Type Unspecified
LAH76714Medicare UPIN