Basic Information
| Provider Information | |||||||||
| NPI: | 1457389041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IKHISEMOJIE | ||||||||
| FirstName: | AUGUSTA | ||||||||
| MiddleName: | UAYEMEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60790 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911166790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267956596 | ||||||||
| FaxNumber: | 7707016655 | ||||||||
| Practice Location | |||||||||
| Address1: | 6485 DAY ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514136433 | ||||||||
| FaxNumber: | 9514136633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | CA | N | Other Service Providers | Acupuncturist | 208VP0000X | A67133 | CA | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207L00000X | A67133 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207Q00000X | P1462 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208VP0000X | P1462 | TX | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A671330 | 01 | CA | BLUE SHIELD | OTHER | 00A671330 | 05 | CA | MEDICAID | P1462 | 01 | TX | MEDICARE ID - TYPE UNSPECIFIED | OTHER |