Healthcare Provider Details

I. General information

NPI: 1528025525
Provider Name (Legal Business Name): ABIODUN O KUKU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 ROSS ST
OAK GROVE LA
71263-9798
US

IV. Provider business mailing address

706 ROSS ST
OAK GROVE LA
71263-9798
US

V. Phone/Fax

Practice location:
  • Phone: 318-428-3237
  • Fax: 318-428-6180
Mailing address:
  • Phone: 318-428-3237
  • Fax: 318-428-6180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number12964R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE3852
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: