Provider Demographics
NPI:1063612885
Name:UDOH, ETEAKAMBA (MD)
Entity type:Individual
Prefix:
First Name:ETEAKAMBA
Middle Name:
Last Name:UDOH
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 1:101 S PARK LN
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5731
Mailing Address - Country:US
Mailing Address - Phone:580-379-6140
Mailing Address - Fax:580-379-6149
Practice Address - Street 1:101 S PARK LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521
Practice Address - Country:US
Practice Address - Phone:580-379-6140
Practice Address - Fax:580-379-6149
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK33569207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program