Provider Demographics
NPI:1912924549
Name:MOMODU, JUDE J (MD)
Entity type:Individual
Prefix:DR
First Name:JUDE
Middle Name:J
Last Name:MOMODU
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 1:3737 N MERIDIAN ST STE 501
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4383
Mailing Address - Country:US
Mailing Address - Phone:317-493-1053
Mailing Address - Fax:317-426-2208
Practice Address - Street 1:3737 N MERIDIAN ST STE 501
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4383
Practice Address - Country:US
Practice Address - Phone:317-493-1053
Practice Address - Fax:317-426-2208
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057399A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D2052802OtherCLIA (CMS)
IN200432610AMedicaid
IN300012343Medicaid
IN200432610AMedicaid