=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740544998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IKEMEFUNA AKUSOBA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2012
-----------------------------------------------------
Last Update Date | 08/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 CETRONIA RD STE 205N
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-426-2600
-----------------------------------------------------
Fax | 833-816-7512
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 CETRONIA RD STE 205N
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104-9263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-426-2600
-----------------------------------------------------
Fax | 833-816-7512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD455576
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------