Healthcare Provider Details

I. General information

NPI: 1407086333
Provider Name (Legal Business Name): UDEME EKPENYONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 N. 4TH ST.
LONGVIEW TX
75601
US

IV. Provider business mailing address

818 N. 4TH ST.
LONGVIEW TX
75601
US

V. Phone/Fax

Practice location:
  • Phone: 903-236-8600
  • Fax: 903-236-8605
Mailing address:
  • Phone: 903-236-8600
  • Fax: 903-236-8605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberP2982
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP2982
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: