1912047382 NPI number — DR. OLUNWA CHISARA IKPEAZU M.D.

Table of content: MARIAM PULLES (NPI 1770382509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912047382 NPI number — DR. OLUNWA CHISARA IKPEAZU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IKPEAZU
Provider First Name:
OLUNWA
Provider Middle Name:
CHISARA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912047382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6944 NW 126TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARKLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33076-1964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-579-2242
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9120A WILES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33067-1993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-341-0074
Provider Business Practice Location Address Fax Number:
954-345-3474
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME 100885 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000633700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3820581 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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