Provider Demographics
NPI:1528158292
Name:ODENHEIMER, REYNARD C (MD)
Entity type:Individual
Prefix:DR
First Name:REYNARD
Middle Name:C
Last Name:ODENHEIMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 W MCNEESE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5558
Mailing Address - Country:US
Mailing Address - Phone:337-439-5888
Mailing Address - Fax:337-439-0808
Practice Address - Street 1:646 W MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5558
Practice Address - Country:US
Practice Address - Phone:337-439-5888
Practice Address - Fax:337-439-0808
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD0201592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1684821Medicaid
LA1684821Medicaid
LAF71472Medicare UPIN