Healthcare Provider Details

I. General information

NPI: 1568965390
Provider Name (Legal Business Name): UCHE IKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2018
Last Update Date: 08/17/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MAR WALT DR UNIT C
FORT WALTON BEACH FL
32547
US

IV. Provider business mailing address

3112 W WARREN BLVD APT 2E
CHICAGO IL
60612-1965
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax: 877-413-5104
Mailing address:
  • Phone: 910-366-3970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME155245
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: