Provider Demographics
NPI:1689248189
Name:EDEM-ENANG, BARTHOLOMEW A (PHD STUDENT)
Entity Type:Individual
Prefix:
First Name:BARTHOLOMEW
Middle Name:A
Last Name:EDEM-ENANG
Suffix:
Gender:M
Credentials:PHD STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4865
Mailing Address - Country:US
Mailing Address - Phone:626-817-1095
Mailing Address - Fax:
Practice Address - Street 1:6833 INDIANA AVE STE 208
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4223
Practice Address - Country:US
Practice Address - Phone:951-660-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program