Healthcare Provider Details

I. General information

NPI: 1730490137
Provider Name (Legal Business Name): JERRY A OKONKWOAGUOLU MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15603 HAWTHORNE BLVD
LAWNDALE CA
90260-2639
US

IV. Provider business mailing address

15603 HAWTHORNE BLVD
LAWNDALE CA
90260-2639
US

V. Phone/Fax

Practice location:
  • Phone: 310-644-4488
  • Fax: 310-679-4035
Mailing address:
  • Phone: 310-644-4488
  • Fax: 310-679-4035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY A OKONKWOAGUOLU
Title or Position: PRESIDENT
Credential:
Phone: 310-644-4488