Provider Demographics
NPI:1043267818
Name:UWAIFO, GABRIEL IKPONMOSA (MD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:IKPONMOSA
Last Name:UWAIFO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-2101
Practice Address - Street 1:751 N RUTLEDGE ST STE 1700
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-1229
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19937207RE0101X
IL036.166674207R00000X, 207RE0101X
LAMD.203716207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036166674Medicaid
MD401048500Medicaid
VA58884349Medicaid
DC034604200Medicaid
AL106178Medicaid
MS106178Medicaid
MS05538368Medicaid
LA1393959Medicaid
MS512I100003Medicare PIN
DC034604200Medicaid
MD401048500Medicaid
DCH80293Medicare UPIN
MS05538368Medicaid
LA1393959Medicaid