Provider Demographics
NPI:1326203035
Name:IKEDIOBI, OKWUOLISA AMECHI (MD)
Entity Type:Individual
Prefix:
First Name:OKWUOLISA
Middle Name:AMECHI
Last Name:IKEDIOBI
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 1:2500 MARYLAND RD
Mailing Address - Street 2:STE 400
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1225
Mailing Address - Country:US
Mailing Address - Phone:215-728-6900
Mailing Address - Fax:215-214-1425
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-2844
Practice Address - Fax:215-214-1425
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD444511207Q00000X, 208M00000X
KY44375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNVAD000OtherFEDERAL UPIN
KYK020340Medicare PIN