Basic Information
Provider Information | |||||||||
NPI: | 1326203035 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IKEDIOBI | ||||||||
FirstName: | OKWUOLISA | ||||||||
MiddleName: | AMECHI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2500 MARYLAND RD | ||||||||
Address2: | STE 400 | ||||||||
City: | WILLOW GROVE | ||||||||
State: | PA | ||||||||
PostalCode: | 190901225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157286900 | ||||||||
FaxNumber: | 2152141425 | ||||||||
Practice Location | |||||||||
Address1: | 333 COTTMAN AVE | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191112434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157282844 | ||||||||
FaxNumber: | 2152141425 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2008 | ||||||||
LastUpdateDate: | 05/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD444511 | PA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 208M00000X | MD444511 | PA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207Q00000X | 44375 | KY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | VAD000 | 01 | TN | FEDERAL UPIN | OTHER |