Provider Demographics
NPI:1447213194
Name:UKEGBU, IBIDUNNI OMOLAYO (MD)
Entity Type:Individual
Prefix:
First Name:IBIDUNNI
Middle Name:OMOLAYO
Last Name:UKEGBU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 BOLTON BOONE DR
Mailing Address - Street 2:STE 103
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2019
Mailing Address - Country:US
Mailing Address - Phone:469-453-2008
Mailing Address - Fax:469-449-0286
Practice Address - Street 1:3506 21ST ST
Practice Address - Street 2:STE 401
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-725-4130
Practice Address - Fax:806-723-7137
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3859207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159628003Medicaid
H59880Medicare UPIN
TX8C7370Medicare ID - Type Unspecified