Healthcare Provider Details

I. General information

NPI: 1427288174
Provider Name (Legal Business Name): IFIOK AKPAN IDEM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501-2431
US

IV. Provider business mailing address

12101 RAYNER PL
AUSTIN TX
78738-6059
US

V. Phone/Fax

Practice location:
  • Phone: 512-730-3056
  • Fax: 888-730-1925
Mailing address:
  • Phone: 216-682-5519
  • Fax: 888-730-1925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101249474
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.097385
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01073264A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number44424
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM14550
License Number StateID
# 6
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2012-01286
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberP9879
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: