Healthcare Provider Details

I. General information

NPI: 1972524049
Provider Name (Legal Business Name): IKEMEFUNA NKANGINIEME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4735 BELPAR ST NW
CANTON OH
44718-3648
US

IV. Provider business mailing address

4735 BELPAR ST NW
CANTON OH
44718-3648
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-9822
  • Fax: 330-493-9816
Mailing address:
  • Phone: 330-493-9822
  • Fax: 330-493-9816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.078767
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD418915
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: