Healthcare Provider Details

I. General information

NPI: 1245469444
Provider Name (Legal Business Name): ODEY CHUKWUEMEKA UKPO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 N MISSION RD
LOS ANGELES CA
90033-1017
US

IV. Provider business mailing address

1104 N MISSION RD
LOS ANGELES CA
90033-1017
US

V. Phone/Fax

Practice location:
  • Phone: 323-343-0512
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2009012284
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberA129278
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: