Provider Demographics
NPI:1588659924
Name:IDAHOSA, EROMONSELE O (MD)
Entity Type:Individual
Prefix:
First Name:EROMONSELE
Middle Name:O
Last Name:IDAHOSA
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 1:8354 LITTLE EAGLE COURT
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234
Mailing Address - Country:US
Mailing Address - Phone:317-291-1211
Mailing Address - Fax:317-291-1194
Practice Address - Street 1:8354 LITTLE EAGLE COURT
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234
Practice Address - Country:US
Practice Address - Phone:317-291-1211
Practice Address - Fax:317-291-1194
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057350A174400000X, 207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200811720Medicaid
IN200811720Medicaid
IN233760BMedicare PIN
INI47559Medicare UPIN