Provider Demographics
NPI:1598857682
Name:EDOKA, EMMANUEL CHUKWELO (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:CHUKWELO
Last Name:EDOKA
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 1:3708 JEFFERSON ST STE A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6206
Mailing Address - Country:US
Mailing Address - Phone:512-459-6503
Mailing Address - Fax:512-454-7453
Practice Address - Street 1:3708 JEFFERSON ST STE A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6206
Practice Address - Country:US
Practice Address - Phone:512-459-6503
Practice Address - Fax:512-454-7453
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4786207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K87XOtherBCBS
TX135683409Medicaid
TX8A2403Medicare PIN
TX00K87XOtherBCBS