Provider Demographics
NPI:1962423848
Name:I D MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:I D MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VITALIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:OKECHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-407-1955
Mailing Address - Street 1:1119 PRUDHOMME CIR
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6544
Mailing Address - Country:US
Mailing Address - Phone:337-407-1955
Mailing Address - Fax:337-407-1956
Practice Address - Street 1:1119 PRUDHOMME CIR
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6544
Practice Address - Country:US
Practice Address - Phone:337-407-1955
Practice Address - Fax:337-407-1956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15601R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1 07409 8Medicaid
I44409Medicare UPIN