1912924549 NPI number — DR. JUDE J MOMODU M.D.

Table of content: DR. JUDE J MOMODU M.D. (NPI 1912924549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912924549 NPI number — DR. JUDE J MOMODU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOMODU
Provider First Name:
JUDE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912924549
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3737 N MERIDIAN ST STE 501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46208-4383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-493-1053
Provider Business Mailing Address Fax Number:
317-426-2208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3737 N MERIDIAN ST STE 501
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46208-4383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-493-1053
Provider Business Practice Location Address Fax Number:
317-426-2208
Provider Enumeration Date:
07/17/2006

Additional Information

			
		

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01057399A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15D2052802 . This is a "CLIA (CMS)" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200432610A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300012343 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".