Provider Demographics
NPI:1821076183
Name:MOMODU, IFEANYI
Entity Type:Individual
Prefix:
First Name:IFEANYI
Middle Name:
Last Name:MOMODU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LAUCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-5501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 LAUCHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5501
Practice Address - Country:US
Practice Address - Phone:910-291-6904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD28234207R00000X
NC2008-01217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC562413454OtherTIN
SCGP3914Medicaid
SC28234OtherLICENSE NUMBER
SC90180OtherSCPCF
SCGP3438Medicaid
NC1821076183Medicaid
SC20045701OtherSELECT HEALTH
SC05714340OtherECF MG NUMBER
SCJBM03354OtherCERT OF LIABILITY INS
SC282349Medicaid
SC571134452OtherTIN CLINIC #2
SC05714340OtherECF MG NUMBER
SCAA11457285Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
SCGP3438Medicaid
SC571134452OtherTIN CLINIC #2
SC90180OtherSCPCF