Provider Demographics
NPI:1255745626
Name:EZEDI, IKEMEFUNA IKEM (DO)
Entity type:Individual
Prefix:DR
First Name:IKEMEFUNA
Middle Name:IKEM
Last Name:EZEDI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:IKEMEFUNA
Other - Middle Name:IKEM
Other - Last Name:EZEDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:34800 BOB WILSON DR DEPT OF
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:619-532-9795
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR DEPT OF
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204201208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice