MEDICARE: DR. IREDIA JOE EKUKPE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6330TG	TX

General Provider Information

NPI Number	:	1609827765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IREDIA JOE EKUKPE O.D.

Provider Business Mailing Address
First Line	:	655 W ILLINOIS AVE
Second Line	:	#911
City	:	DALLAS
State	:	TX
Zip	:	75224-1817
Country	:	US
Telephone Number	:	214-941-9600
Fax Number	:	214-941-9623

Provider Business Practice Location Address
First Line	:	655 W ILLINOIS AVE
Second Line	:	#911
City	:	DALLAS
State	:	TX
Zip	:	75224-1817
Country	:	US
Telephone Number	:	214-941-9600
Fax Number	:	214-941-9623

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2006
Last Update Date	:	07/09/2007

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