1659374601 NPI number — WENDY TIPTON OBERDICK MD

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	OBERDICK
Provider First Name	:	WENDY
Provider Middle Name	:	TIPTON
Provider Name Prefix Text	:
Provider Name Suffix Text	:
Provider Credential Text	:	MD
Provider Gender Code	:	F

Provider Other Organization Name	:
Provider Other Organization Name Type Code	:
Provider Other Last Name	:	TIPTON
Provider Other First Name	:	WENDY
Provider Other Middle Name	:	NANETTE
Provider Other Name Prefix Text	:	DR.
Provider Other Name Suffix Text	:
Provider Other Credential Text	:	MD
Provider Other Last Name Type Code	:	1

NPI Number	:	1659374601
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	05/07/2008
NPI Deactivation Reason Code	:
NPI Deactivation Date	:	05/23/2005
NPI Reactivation Date	:	05/24/2005

Provider First Line Business Mailing Address	:	1514 JEFFERSON HWY
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	NEW ORLEANS
Provider Business Mailing Address State Name	:	LA
Provider Business Mailing Address Postal Code	:	70121
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	5048424000
Provider Business Mailing Address Fax Number	:

Provider First Line Business Practice Location Address	:	2750 GAUSE BOULEVARD
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	SLIDELL
Provider Business Practice Location Address State Name	:	LA
Provider Business Practice Location Address Postal Code	:	70461
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	9856393777
Provider Business Practice Location Address Fax Number	:
Provider Enumeration Date	:	05/23/2005

Authorized Official Last Name	:
Authorized Official First Name	:
Authorized Official Middle Name	:
Authorized Official Title or Position	:
Authorized Official Telephone Number	:

• Taxonomy code: 207Q00000X , with the licence number:  MD200133 , registered in the state of LA .
• Taxonomy code: 207Q00000X , with the licence number: 200133 , registered in the state of LA .

• Identifier: G65207 . This identifiers is of the category "".
• Identifier: 4J660 , issued by the state of ( LA ) . This identifiers is of the category "".
• Identifier: 1623512 , issued by the state of ( LA ) . This identifiers is of the category "".
• Identifier: 4J6606629 , issued by the state of ( LA ) . This identifiers is of the category "".