Provider Demographics
NPI:1659453173
Name:IGHAMA AMEGOR, IBILOLA (MD)
Entity Type:Individual
Prefix:
First Name:IBILOLA
Middle Name:
Last Name:IGHAMA AMEGOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 CHANCELLOR AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2248
Mailing Address - Country:US
Mailing Address - Phone:973-926-4400
Mailing Address - Fax:973-926-4660
Practice Address - Street 1:88 CHANCELLOR AVENUE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2248
Practice Address - Country:US
Practice Address - Phone:973-926-4400
Practice Address - Fax:973-926-4660
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA61110208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6467105Medicaid
NJ6467105Medicaid