Provider Demographics
NPI:1962664615
Name:IMMANUEL, KEVIN EMITSEILU (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:EMITSEILU
Last Name:IMMANUEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EMITSEILU
Other - Middle Name:KEVIN
Other - Last Name:ILUONAKHAMHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6565 FANNIN ST # B452
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:404-723-8449
Mailing Address - Fax:
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:B452
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:404-723-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP66482084N0400X
GA003058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8FU287OtherBLUE CROSS BLUE SHIELD
TX340111901Medicaid
TX355682YMVQMedicare PIN
TX355682ZSWDMedicare PIN