Provider Demographics
NPI:1538182571
Name:IBEANU, OKECHUKWU ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:OKECHUKWU
Middle Name:ANTHONY
Last Name:IBEANU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9135 PISCATAWAY RD STE 420
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2555
Mailing Address - Country:US
Mailing Address - Phone:301-828-2555
Mailing Address - Fax:
Practice Address - Street 1:9135 PISCATAWAY RD STE 420
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2555
Practice Address - Country:US
Practice Address - Phone:301-828-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15442R207V00000X
PAMD423582207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103065271Medicaid
LA1074497Medicaid
PA103065271Medicaid
LA4J048Medicare PIN
LA$$$$$$$$$0OtherBLUE CROSS BLUE SHIELD
LA1074497Medicaid