Basic Information
| Provider Information | |||||||||
| NPI: | 1194776708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ILOABACHIE | ||||||||
| FirstName: | KENNY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ILOABACHIE | ||||||||
| OtherFirstName: | KENNY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1320 SUMMER LEE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727715443 | ||||||||
| FaxNumber: | 9727715444 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 SUMMER LEE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727715443 | ||||||||
| FaxNumber: | 9727715444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 200733 | LA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Y00000X | 200733 | LA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | N2123 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.