Healthcare Provider Details

I. General information

NPI: 1245791888
Provider Name (Legal Business Name): ESEIGBORIA J IKHELOA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE STREET UMSOM DEPARTMENT OF PEDIATRICS ROOM N5W70
BALTIMORE MD
21201
US

IV. Provider business mailing address

22 S. GREENE STREET UMSOM-DEPARTMENT OF PEDIATRICS-ROOM N5W70
BALTIMORE MD
21201
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0093890
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: