Basic Information
| Provider Information | |||||||||
| NPI: | 1235233545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IDEMUNDIA | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | OVBIYE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IDEMUNDIA | ||||||||
| OtherFirstName: | ANN | ||||||||
| OtherMiddleName: | OMOROVBIYE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2310 HOLMES ST | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641082602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162182500 | ||||||||
| FaxNumber: | 8164217379 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 055066 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 54911 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 2014039523 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | C54911 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 321114199A | 05 | GA | MEDICAID | 589412 | 01 | GA | BCBS - LMAC | OTHER | 894211 | 01 | GA | BCBS - EAPC | OTHER | 373267 | 01 | GA | AETNA | OTHER |