Provider Demographics
NPI:1699932707
Name:EBONG, IMO ASUQUO (MD,MS)
Entity type:Individual
Prefix:
First Name:IMO
Middle Name:ASUQUO
Last Name:EBONG
Suffix:
Gender:F
Credentials:MD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 Y ST STE 2860
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-8426
Mailing Address - Fax:
Practice Address - Street 1:4860 Y ST STE 2860
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-8426
Practice Address - Fax:916-734-6474
Is Sole Proprietor?:No
Enumeration Date:2008-05-18
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119607207R00000X, 207RC0000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902846306OtherGROUP NPI
CAGR0100430OtherGROUP MEDI-CAL
CAW18762OtherGROUP MEDICARE
CAGR0100430OtherGROUP MEDI-CAL