Healthcare Provider Details

I. General information

NPI: 1265684716
Provider Name (Legal Business Name): EDIDIONG NSIDIBE IKPE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EDIDIONG NSIDIBE IKPE-EKPO MPH

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7236 AMIGO AVE
RESEDA CA
91335-8108
US

IV. Provider business mailing address

3495 PIEDMONT RD NE
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 203-500-5317
  • Fax:
Mailing address:
  • Phone: 404-365-0966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number065466
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA99823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: