Provider Demographics
NPI:1124061817
Name:ETIM, KENYA SEKONI (MD)
Entity type:Individual
Prefix:DR
First Name:KENYA
Middle Name:SEKONI
Last Name:ETIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 NACOGDOCHES ST STE 280
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2444
Mailing Address - Country:US
Mailing Address - Phone:903-541-5396
Mailing Address - Fax:
Practice Address - Street 1:203 NACOGDOCHES ST STE 280
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2444
Practice Address - Country:US
Practice Address - Phone:903-541-5396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076863207QA0505X
TXT0200207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKS076863OtherBCBS
MI1124061817Medicaid
MI7200526OtherAETNA
MI0170255OtherPHPFC
MI4599009Medicaid
MIP32269FOtherBCN
MI01-01528OtherPHP-MM
MII00864Medicare UPIN
MI4599009Medicaid
MI1124061817Medicaid