MEDICARE: NKOLI ANIGBOGU MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	C170662	CA
2	207R00000X	Internal Medicine Physician	01084495A	IN
3	207R00000X	Internal Medicine Physician	35-0803901-A	OH
4	208M00000X	Hospitalist Physician	35.083901	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184710121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NKOLI ANIGBOGU MD

Provider Business Mailing Address
First Line	:	3130 N COUNTY ROAD 25A
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-1337
Country	:	US
Telephone Number	:	937-440-4466
Fax Number	:	937-440-4470

Provider Business Practice Location Address
First Line	:	1050 KENDALL DR STE F
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-4125
Country	:	US
Telephone Number	:	909-352-6655
Fax Number	:	909-352-6770

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	05/05/2023

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Directions to “ NKOLI ANIGBOGU MD” Practice Location

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