Provider Demographics
NPI:1225473929
Name:WANKO MBOUMI, IGOR (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:WANKO MBOUMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5255 E STOP 11 RD STE 450
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6342
Practice Address - Country:US
Practice Address - Phone:317-865-4800
Practice Address - Fax:317-865-4806
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI68807208600000X
IN01082242A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery