Provider Demographics
NPI:1508846783
Name:IBOAYA, IYABO A (MD)
Entity Type:Individual
Prefix:
First Name:IYABO
Middle Name:A
Last Name:IBOAYA
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 1:121 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4340
Mailing Address - Country:US
Mailing Address - Phone:419-998-4388
Mailing Address - Fax:
Practice Address - Street 1:1005 BELLEFONTAINE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2851
Practice Address - Country:US
Practice Address - Phone:419-227-5298
Practice Address - Fax:419-227-5879
Is Sole Proprietor?:No
Enumeration Date:2006-01-22
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014445207P00000X
OH35092246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09379834Medicaid
OH2902970Medicaid
OH2902970Medicaid
MS080001566Medicare PIN
OH4253491Medicare PIN