Healthcare Provider Details

I. General information

NPI: 1811206337
Provider Name (Legal Business Name): OMONIGHO EKHOMU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

575 W MADISON ST APT 1701
CHICAGO IL
60661-2647
US

V. Phone/Fax

Practice location:
  • Phone: 312-208-8157
  • Fax:
Mailing address:
  • Phone: 312-208-8157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125056014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: