Provider Demographics
NPI:1154412963
Name:AUGUSTA U. IKHISEMOJIE, M.D., A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:AUGUSTA U. IKHISEMOJIE, M.D., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTA
Authorized Official - Middle Name:UAYEMEN
Authorized Official - Last Name:IKHISEMOJIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-276-1688
Mailing Address - Street 1:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-396-0851
Practice Address - Street 1:6485 DAY ST STE 305
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0926
Practice Address - Country:US
Practice Address - Phone:951-413-6433
Practice Address - Fax:951-413-6633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171100000X
CAA67133207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H40996Medicare UPIN