Provider Demographics
NPI:1336397306
Name:EDOSOMWAN-EIGBE, EMMANUEL O (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:O
Last Name:EDOSOMWAN-EIGBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EMMANUEL
Other - Middle Name:
Other - Last Name:EDSOMWAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1805 MILTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-2437
Mailing Address - Country:US
Mailing Address - Phone:704-535-0400
Mailing Address - Fax:704-535-3443
Practice Address - Street 1:1805 MILTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-2437
Practice Address - Country:US
Practice Address - Phone:704-535-0400
Practice Address - Fax:704-535-3443
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913749Medicaid
NCNC1614CMedicare PIN
NC5913749Medicaid
NCNC1614EMedicare PIN
NCNC1614DMedicare PIN