Healthcare Provider Details

I. General information

NPI: 1770570442
Provider Name (Legal Business Name): EMMANUEL O EMENIKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2005
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4954 VAN NUYS BLVD STE 202
SHERMAN OAKS CA
91403
US

IV. Provider business mailing address

11693 SAN VICENTE BLVD # 112
LOS ANGELES CA
90049-5105
US

V. Phone/Fax

Practice location:
  • Phone: 310-340-5510
  • Fax:
Mailing address:
  • Phone: 310-340-5510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA92212
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA92212
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License NumberA92212
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberA92212
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA92212
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA92212
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA92212
License Number StateCA
# 8
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA92212
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: