Provider Demographics
NPI:1194974535
Name:ODIBO, IMELDA NGOZI (MD)
Entity type:Individual
Prefix:
First Name:IMELDA
Middle Name:NGOZI
Last Name:ODIBO
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-662-9480
Mailing Address - Fax:910-662-9490
Practice Address - Street 1:2150 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8052
Practice Address - Country:US
Practice Address - Phone:910-662-9480
Practice Address - Fax:910-662-9490
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00559207VM0101X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCO704AMedicare PIN
NC1194974535Medicaid