Healthcare Provider Details

I. General information

NPI: 1588991855
Provider Name (Legal Business Name): ENANORE E OKUMAGBA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2009
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5751 UNIVERSITY AVE #108 BOX 410
INDIANAPOLIS IN
46219-7222
US

IV. Provider business mailing address

950 N. MERIDIAN STREET PROVIDER ENROLLMENT SUITE 500
INDIANAPOLIS IN
46204-3908
US

V. Phone/Fax

Practice location:
  • Phone: 317-927-1761
  • Fax: 407-767-0750
Mailing address:
  • Phone: 317-962-4944
  • Fax: 317-962-4950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2009-01946
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2009-01946
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01069813
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: