Healthcare Provider Details

I. General information

NPI: 1154412963
Provider Name (Legal Business Name): AUGUSTA U. IKHISEMOJIE, M.D., A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6485 DAY ST STE 305
RIVERSIDE CA
92507-0926
US

IV. Provider business mailing address

PO BOX 60790
PASADENA CA
91116-6790
US

V. Phone/Fax

Practice location:
  • Phone: 951-413-6433
  • Fax: 951-413-6633
Mailing address:
  • Phone: 626-795-6596
  • Fax: 626-396-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA67133
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA67133
License Number StateCA

VIII. Authorized Official

Name: DR. AUGUSTA UAYEMEN IKHISEMOJIE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-276-1688