Provider Demographics
NPI:1669561122
Name:EDIBIOKPO, EMMANUEL AMINONE (DO)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:AMINONE
Last Name:EDIBIOKPO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8656 W GAGE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7145
Mailing Address - Country:US
Mailing Address - Phone:509-736-0551
Mailing Address - Fax:
Practice Address - Street 1:8656 W GAGE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7145
Practice Address - Country:US
Practice Address - Phone:509-736-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA15630Medicare UPIN
AB13705Medicare ID - Type Unspecified