Provider Demographics
NPI:1336135540
Name:IKENBERRY, STEVEN O (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:O
Last Name:IKENBERRY
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 1:401 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5075
Mailing Address - Country:US
Mailing Address - Phone:815-397-7340
Mailing Address - Fax:815-397-7388
Practice Address - Street 1:401 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5075
Practice Address - Country:US
Practice Address - Phone:815-397-7340
Practice Address - Fax:815-397-7388
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36093860207RG0100X
IN01039865A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093860Medicaid
IL036093860Medicaid