Provider Demographics
NPI:1144335126
Name:OUEDRAOGO, GHISLAINE LAISSA (M D)
Entity type:Individual
Prefix:
First Name:GHISLAINE
Middle Name:LAISSA
Last Name:OUEDRAOGO
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 758963
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8963
Mailing Address - Country:US
Mailing Address - Phone:804-822-4355
Mailing Address - Fax:
Practice Address - Street 1:12 N THOMPSON ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-2718
Practice Address - Country:US
Practice Address - Phone:804-359-9861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAI65490Medicare UPIN