Healthcare Provider Details

I. General information

NPI: 1508286485
Provider Name (Legal Business Name): IKECHI KONKWO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 S STATE ST
DOVER DE
19901-6927
US

IV. Provider business mailing address

1275 S STATE ST
DOVER DE
19901-6927
US

V. Phone/Fax

Practice location:
  • Phone: 302-672-2319
  • Fax: 302-672-2341
Mailing address:
  • Phone: 302-672-2319
  • Fax: 302-672-2341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberC1-0012159
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: