Provider Demographics
NPI:1205897865
Name:IWELUMO, IFEOMA (MD)
Entity type:Individual
Prefix:DR
First Name:IFEOMA
Middle Name:
Last Name:IWELUMO
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 1:266 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-4026
Mailing Address - Country:US
Mailing Address - Phone:973-340-1222
Mailing Address - Fax:
Practice Address - Street 1:266 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-4026
Practice Address - Country:US
Practice Address - Phone:973-340-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA051800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6090303Medicaid