Provider Demographics
NPI:1962629253
Name:EKONG, THEODORE O
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:O
Last Name:EKONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 EASTWAY DR
Mailing Address - Street 2:STE. 109
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5643
Mailing Address - Country:US
Mailing Address - Phone:704-536-5911
Mailing Address - Fax:704-536-9770
Practice Address - Street 1:3127 EASTWAY DR
Practice Address - Street 2:STE. 109
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5643
Practice Address - Country:US
Practice Address - Phone:704-536-5911
Practice Address - Fax:704-536-9770
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00651332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703516Medicaid