Provider Demographics
NPI:1104845304
Name:OFOMATA, IKECHUKWU ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:IKECHUKWU
Middle Name:ROBERT
Last Name:OFOMATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2709 BITTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-5208
Mailing Address - Country:US
Mailing Address - Phone:214-330-0036
Mailing Address - Fax:214-337-3905
Practice Address - Street 1:1350 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1654
Practice Address - Country:US
Practice Address - Phone:214-330-0036
Practice Address - Fax:214-337-3905
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL58572084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1600066-10Medicaid
TXH91056Medicare UPIN