Provider Demographics
NPI:1376503144
Name:KELLY-DOKUBO, IDUAMA (MD)
Entity Type:Individual
Prefix:DR
First Name:IDUAMA
Middle Name:
Last Name:KELLY-DOKUBO
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:PO BOX 50082
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91115-0082
Mailing Address - Country:US
Mailing Address - Phone:626-296-0792
Mailing Address - Fax:
Practice Address - Street 1:2750 E WASHINGTON BLVD
Practice Address - Street 2:SUITE #370
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1448
Practice Address - Country:US
Practice Address - Phone:626-296-0792
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51025207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG51025Medicare ID - Type Unspecified