Healthcare Provider Details

I. General information

NPI: 1689684839
Provider Name (Legal Business Name): WALTER C IFEADIKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 HUMPHREYS BLVD STE 300
MEMPHIS TN
38120-2382
US

IV. Provider business mailing address

PO BOX 405827
ATLANTA GA
30384-5800
US

V. Phone/Fax

Practice location:
  • Phone: 901-227-9870
  • Fax: 901-227-9879
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number38519
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number54786
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: