Provider Demographics
NPI:1730765272
Name:DEDE, IBINABO (MD)
Entity type:Individual
Prefix:
First Name:IBINABO
Middle Name:
Last Name:DEDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IBINABO
Other - Middle Name:
Other - Last Name:OBUOFORIBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1505 EASTLAND DR STE 330
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7912
Mailing Address - Country:US
Mailing Address - Phone:309-662-3311
Mailing Address - Fax:309-662-9709
Practice Address - Street 1:1505 EASTLAND DR STE 330
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7912
Practice Address - Country:US
Practice Address - Phone:309-662-3311
Practice Address - Fax:309-662-9709
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036169126207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program