Provider Demographics
NPI:1215453881
Name:IGBOELI, PROSPER I
Entity type:Individual
Prefix:
First Name:PROSPER
Middle Name:I
Last Name:IGBOELI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 AYLESBURY DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-8214
Mailing Address - Country:US
Mailing Address - Phone:440-796-7593
Mailing Address - Fax:
Practice Address - Street 1:1417 AYLESBURY DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-8214
Practice Address - Country:US
Practice Address - Phone:440-796-7593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202500207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology