Provider Demographics
NPI:1992556435
Name:IWENOFU, EMEKA
Entity type:Individual
Prefix:MR
First Name:EMEKA
Middle Name:
Last Name:IWENOFU
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:EMMY
Other - Middle Name:
Other - Last Name:IWENOFU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12610 TRISKETT RD # M11
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-2541
Mailing Address - Country:US
Mailing Address - Phone:216-255-1395
Mailing Address - Fax:
Practice Address - Street 1:10533 BALTIC RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-1634
Practice Address - Country:US
Practice Address - Phone:216-255-1395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
OHRW713755172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver