Basic Information
| Provider Information | |||||||||
| NPI: | 1720492234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IKWUEME | ||||||||
| FirstName: | FIDELIS | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 86 W UNDERWOOD ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889123648 | ||||||||
| FaxNumber: | 3218414085 | ||||||||
| Practice Location | |||||||||
| Address1: | 86 W UNDERWOOD ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889123648 | ||||||||
| FaxNumber: | 3218414085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2014 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30669 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME130092 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | ME130092 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 020611600 | 05 | FL | MEDICAID |