Healthcare Provider Details

I. General information

NPI: 1700075686
Provider Name (Legal Business Name): EFEM IMOKE, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4713 LEEDS AVE
BALTIMORE MD
21227-1402
US

IV. Provider business mailing address

4713 LEEDS AVE
BALTIMORE MD
21227-1402
US

V. Phone/Fax

Practice location:
  • Phone: 410-247-4740
  • Fax: 410-247-2346
Mailing address:
  • Phone: 410-247-4740
  • Fax: 410-247-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0025902
License Number StateMD

VIII. Authorized Official

Name: MRS. CAROL LYN CWIK
Title or Position: DIRECTOR OF ADMINISTRATIVE AFFAIRS
Credential:
Phone: 410-247-4740