Provider Demographics
NPI:1750465654
Name:IGBASEIMOKUMO, USIAKIMI (MBBS, FRCS(C), MD)
Entity Type:Individual
Prefix:
First Name:USIAKIMI
Middle Name:
Last Name:IGBASEIMOKUMO
Suffix:
Gender:M
Credentials:MBBS, FRCS(C), MD
Other - Prefix:
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Other - Middle Name:
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Other - Last Name Type:
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Mailing Address - Street 1:PO BOX 5865
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-5865
Mailing Address - Country:US
Mailing Address - Phone:806-743-2898
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:4102 24TH ST STE 504
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-743-7700
Practice Address - Fax:806-743-7703
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXFTL41604207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO782343OtherHEALTHLINK
MO205463300Medicaid
MO205463300Medicaid
MOP00389198Medicare PIN
MOP00415608Medicare PIN
MO964135236Medicare PIN
MO782343OtherHEALTHLINK