Provider Demographics
NPI:1831145770
Name:IBIRONKE, JOSEPHINE OLUTOLA (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:OLUTOLA
Last Name:IBIRONKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:
Other - Last Name:OWOEYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:147 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-9118
Mailing Address - Country:US
Mailing Address - Phone:606-218-5525
Mailing Address - Fax:
Practice Address - Street 1:147 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-9118
Practice Address - Country:US
Practice Address - Phone:606-218-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1877152W00000X
KY2041DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405879800Medicaid
MDU97443Medicare UPIN
MD405879800Medicaid