Basic Information
| Provider Information | |||||||||
| NPI: | 1639134588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UDOM | ||||||||
| FirstName: | IZUKA | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8515 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114351879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164593329 | ||||||||
| FaxNumber: | 7189786888 | ||||||||
| Practice Location | |||||||||
| Address1: | 11811 GUY R BREWER BLVD | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189457150 | ||||||||
| FaxNumber: | 7189786888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 169783 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | 169783 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01023505 | 05 | NY | MEDICAID |