Provider Demographics
NPI:1508286485
Name:KONKWO, IKECHI
Entity Type:Individual
Prefix:
First Name:IKECHI
Middle Name:
Last Name:KONKWO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-6927
Mailing Address - Country:US
Mailing Address - Phone:302-672-2319
Mailing Address - Fax:302-672-2341
Practice Address - Street 1:1275 S STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6927
Practice Address - Country:US
Practice Address - Phone:302-672-2319
Practice Address - Fax:302-672-2341
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DEC1-00121592083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program