Provider Demographics
NPI:1891037230
Name:EBONG, IMA MBODIE (MD)
Entity Type:Individual
Prefix:DR
First Name:IMA
Middle Name:MBODIE
Last Name:EBONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 S LIMESTONE KY CLINIC J401
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0284
Mailing Address - Country:US
Mailing Address - Phone:859-323-5661
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE KY CLINIC J401
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536
Practice Address - Country:US
Practice Address - Phone:859-323-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-24
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY513682084N0600X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program