Provider Demographics
NPI:1639424286
Name:ILEKA, JASPER O (PD)
Entity Type:Individual
Prefix:DR
First Name:JASPER
Middle Name:O
Last Name:ILEKA
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 CRYSTAL LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-6660
Mailing Address - Country:US
Mailing Address - Phone:214-275-8066
Mailing Address - Fax:
Practice Address - Street 1:2947 S BUCKNER BLVD
Practice Address - Street 2:#500
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-6952
Practice Address - Country:US
Practice Address - Phone:214-275-8066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI02349183500000X
TX49901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist