Healthcare Provider Details

I. General information

NPI: 1992238760
Provider Name (Legal Business Name): AMORKOR SOGBODJOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4775 E MARYLAND ST
DECATUR IL
62521-8820
US

IV. Provider business mailing address

4775 E MARYLAND ST
DECATUR IL
62521-8820
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-3737
  • Fax:
Mailing address:
  • Phone: 217-864-3737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036167087
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036167087
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: