Provider Demographics
NPI:1932126844
Name:EKELEM, IFEATU (MD)
Entity Type:Individual
Prefix:DR
First Name:IFEATU
Middle Name:
Last Name:EKELEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 W HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0204
Mailing Address - Country:US
Mailing Address - Phone:559-324-6200
Mailing Address - Fax:559-324-6280
Practice Address - Street 1:275 W HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0204
Practice Address - Country:US
Practice Address - Phone:559-324-6200
Practice Address - Fax:559-324-6280
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43177208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF73744Medicare UPIN