Provider Demographics
NPI:1427236215
Name:LYDEN C ODUKWU MD PA
Entity type:Organization
Organization Name:LYDEN C ODUKWU MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYDEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ODUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-620-0520
Mailing Address - Street 1:PO BOX 4516
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704-4516
Mailing Address - Country:US
Mailing Address - Phone:432-620-0525
Mailing Address - Fax:
Practice Address - Street 1:3305 ANDREWS HWY STE B
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-5130
Practice Address - Country:US
Practice Address - Phone:432-620-0525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0036MPOtherBCBS
TXDD7408Medicare PIN
TX00914YMedicare PIN