Provider Demographics
NPI:1457389041
Name:IKHISEMOJIE, AUGUSTA UAYEMEN (MD)
Entity Type:Individual
Prefix:
First Name:AUGUSTA
Middle Name:UAYEMEN
Last Name:IKHISEMOJIE
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:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:770-701-6655
Practice Address - Street 1:6485 DAY ST STE 305
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507
Practice Address - Country:US
Practice Address - Phone:951-413-6433
Practice Address - Fax:951-413-6633
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171100000X
CAA67133208VP0000X, 207L00000X
TXP1462207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A671330OtherBLUE SHIELD
CA00A671330Medicaid
TXP1462OtherMEDICARE ID - TYPE UNSPECIFIED
H40996Medicare UPIN
H40996Medicare UPIN