Provider Demographics
NPI:1790761500
Name:EJIE, UKONU (MD)
Entity Type:Individual
Prefix:DR
First Name:UKONU
Middle Name:
Last Name:EJIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 LACOSTA LN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-8159
Mailing Address - Country:US
Mailing Address - Phone:386-274-1966
Mailing Address - Fax:386-274-1964
Practice Address - Street 1:104 LACOSTA LN
Practice Address - Street 2:SUITE 120
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-8159
Practice Address - Country:US
Practice Address - Phone:386-274-1966
Practice Address - Fax:386-274-1964
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME86706207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
H78003Medicare UPIN