Healthcare Provider Details

I. General information

NPI: 1285973347
Provider Name (Legal Business Name): KELECHI O OGBONNA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2013
Last Update Date: 11/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VINE ST
HARTFORD CT
06112-1639
US

IV. Provider business mailing address

500 VINE ST
HARTFORD CT
06112-1639
US

V. Phone/Fax

Practice location:
  • Phone: 860-293-6418
  • Fax:
Mailing address:
  • Phone: 347-263-7656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number51587
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: