Basic Information
| Provider Information | |||||||||
| NPI: | 1124067798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAURIE | ||||||||
| FirstName: | LOUBA | ||||||||
| MiddleName: | RODENKO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RODENKO | ||||||||
| OtherFirstName: | LOUBA | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 712 N WASHINGTON AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148268822 | ||||||||
| FaxNumber: | 2148269792 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 GASTON AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148268822 | ||||||||
| FaxNumber: | 2148269792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | K0549 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 047354806 | 05 | TX | MEDICAID | 047354808 | 05 | TX | MEDICAID |