Provider Demographics
NPI:1649732884
Name:AVBOVBO, AKPOMEVIGHO A
Entity type:Individual
Prefix:
First Name:AKPOMEVIGHO
Middle Name:A
Last Name:AVBOVBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AKPOMEVIGHO
Other - Middle Name:AISHATU
Other - Last Name:AVBOVBO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2100 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1628
Mailing Address - Country:US
Mailing Address - Phone:434-517-8022
Mailing Address - Fax:
Practice Address - Street 1:2100 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1628
Practice Address - Country:US
Practice Address - Phone:434-517-8022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101274912208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program