Provider Demographics
NPI:1598805574
Name:EGBUNA, IKENNA I (MD)
Entity Type:Individual
Prefix:DR
First Name:IKENNA
Middle Name:I
Last Name:EGBUNA
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 1:3270 JOE BATTLE BLVD
Mailing Address - Street 2:245
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-2639
Mailing Address - Country:US
Mailing Address - Phone:915-702-0165
Mailing Address - Fax:915-702-0167
Practice Address - Street 1:3270 JOE BATTLE BLVD
Practice Address - Street 2:245
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-2639
Practice Address - Country:US
Practice Address - Phone:915-702-0165
Practice Address - Fax:915-702-0167
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070397A207RG0100X
TXP1638207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000750628OtherANTHEM PROVIDER NUMBER
IN201049570Medicaid
NY241127OtherLICENSE
NY241127OtherLICENSE
INM400063152Medicare PIN
INP01044425Medicare PIN