Provider Demographics
NPI:1326019068
Name:AISIKU, IMOIGELE P (MD)
Entity Type:Individual
Prefix:
First Name:IMOIGELE
Middle Name:P
Last Name:AISIKU
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 1:1968 PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1281
Mailing Address - Country:US
Mailing Address - Phone:404-605-2800
Mailing Address - Fax:
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-605-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMCS009935A207P00000X
VA0101233341207P00000X, 207Q00000X
GA046023207P00000X, 2084A2900X, 207RC0200X
TXN8162207P00000X, 207RC0200X
NH23299207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5879680 541581185Medicaid
WI34143200Medicaid
VAH33575Medicare UPIN
VA000382M15 C05015Medicare ID - Type Unspecified
WI34143200Medicaid
VA5879680 541581185Medicaid
WI004101473Medicare PIN
VA00X6025C01Medicare PIN
WI0058Medicare PIN
H12478Medicare UPIN