Provider Demographics
NPI:1689684839
Name:IFEADIKE, WALTER C (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:C
Last Name:IFEADIKE
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6215 HUMPHREYS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2382
Practice Address - Country:US
Practice Address - Phone:901-227-9870
Practice Address - Fax:901-227-9879
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38519207RG0100X
TN547862080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E00932Medicare UPIN
GA000754135ACMedicaid
GA000754135ADMedicaid
GA000754135YMedicaid
E00932Medicare UPIN
GA000754135ABMedicaid