Provider Demographics
NPI:1710085824
Name:EKANEM, IBANGA MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:IBANGA
Middle Name:MICHAEL
Last Name:EKANEM
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 1:100 PADUCAH DR
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155
Mailing Address - Country:US
Mailing Address - Phone:304-455-3611
Mailing Address - Fax:304-455-1778
Practice Address - Street 1:100 PADUCAH DR
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155
Practice Address - Country:US
Practice Address - Phone:304-455-3611
Practice Address - Fax:304-455-1778
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV199222080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1801553000Medicaid