Provider Demographics
NPI:1265684716
Name:IKPE, EDIDIONG NSIDIBE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDIDIONG
Middle Name:NSIDIBE
Last Name:IKPE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:EDIDIONG
Other - Middle Name:NSIDIBE
Other - Last Name:IKPE-EKPO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPH
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-365-0966
Mailing Address - Fax:
Practice Address - Street 1:7236 AMIGO AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-8108
Practice Address - Country:US
Practice Address - Phone:203-500-5317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99823207R00000X
GA065466207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEF015ZMedicare PIN