Provider Demographics
NPI:1235233545
Name:IDEMUNDIA, ANN OMOROVBIYE (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:OMOROVBIYE
Last Name:IDEMUNDIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:OMOROVBIYE
Other - Last Name:IDEMUNDIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2310 HOLMES ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2602
Mailing Address - Country:US
Mailing Address - Phone:816-218-2500
Mailing Address - Fax:816-421-7379
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055066208000000X
CA54911208000000X
MO2014039523208000000X
CAC54911208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA321114199AMedicaid
GA373267OtherAETNA
GA894211OtherBCBS - EAPC
GA589412OtherBCBS - LMAC
GA321114199AMedicaid
GA37BBGQSMedicare ID - Type Unspecified