MEDICARE: IMA UDOM M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1699935791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMA UDOM M.D

Provider Business Mailing Address
First Line	:	4904 MILLER DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-1870
Country	:	US
Telephone Number	:	917-304-7864
Fax Number	:

Provider Business Practice Location Address
First Line	:	2301 ERWIN RD
Second Line	:	DUMC 3935, DUKE NORTH, ROOM 0681
City	:	DURHAM
State	:	NC
Zip	:	27710-0001
Country	:	US
Telephone Number	:	919-681-2247
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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