Provider Demographics
NPI:1457466864
Name:UDO, EDEDET AKPAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDEDET
Middle Name:AKPAN
Last Name:UDO
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 1:2597 FREDERICK DOUGLASS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2105
Mailing Address - Country:US
Mailing Address - Phone:212-234-3433
Mailing Address - Fax:212-234-1197
Practice Address - Street 1:2597 FREDERICK DOUGLASS BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-2105
Practice Address - Country:US
Practice Address - Phone:212-234-3433
Practice Address - Fax:212-234-1197
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202225174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02075510Medicaid
NY02075510Medicaid
NY01P001Medicare ID - Type Unspecified