Healthcare Provider Details

I. General information

NPI: 1235570375
Provider Name (Legal Business Name): CHIBUZO CLEMENT ODIGWE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-9674
  • Fax:
Mailing address:
  • Phone: 800-401-3057
  • Fax: 318-868-6430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number1026720
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number37993
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number37993
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number1026720
License Number StateMA
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1026720
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.063530
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: