Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 025417 | LA |
NPI | 1003846809 |
---|---|
Provider Name | Dr. Leandre W. Odom |
First Address | New Iberia, LA 70560-4091 |
Second Address | New Iberia, LA 70560-4091 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/07/2006 |
Last Update Date | 06/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1576271 | (05) | LA |
H47682 | (02) | LA |