Provider Demographics
NPI:1568667947
Name:ELIJAH, ITORO
Entity Type:Individual
Prefix:
First Name:ITORO
Middle Name:
Last Name:ELIJAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 W BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2984
Mailing Address - Country:US
Mailing Address - Phone:602-237-7373
Mailing Address - Fax:
Practice Address - Street 1:5130 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2984
Practice Address - Country:US
Practice Address - Phone:602-237-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2015-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ46474208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice