Healthcare Provider Details

I. General information

NPI: 1558642744
Provider Name (Legal Business Name): ASSIZAT OGBARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1372 N MILWAUKEE AVE
CHICAGO IL
60622-9149
US

IV. Provider business mailing address

6437 N DAMEN AVE
CHICAGO IL
60645-5613
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-0941
  • Fax:
Mailing address:
  • Phone: 773-772-0941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number051-291725
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: