Basic Information
| Provider Information | |||||||||
| NPI: | 1699960930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBE | ||||||||
| FirstName: | IKENNA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4299 SAN FELIPE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770272916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324763900 | ||||||||
| FaxNumber: | 8324763990 | ||||||||
| Practice Location | |||||||||
| Address1: | 5801 BREMO ROAD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232261907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042850620 | ||||||||
| FaxNumber: | 8042850726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 12/17/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 045650 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0101246080 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05584974 | 01 | ECFMG | OTHER |