Basic Information
| Provider Information | |||||||||
| NPI: | 1265684716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IKPE | ||||||||
| FirstName: | EDIDIONG | ||||||||
| MiddleName: | NSIDIBE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IKPE-EKPO | ||||||||
| OtherFirstName: | EDIDIONG | ||||||||
| OtherMiddleName: | NSIDIBE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MPH | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043650966 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7236 AMIGO AVE | ||||||||
| Address2: | |||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913358108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035005317 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2008 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A99823 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 065466 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.