Healthcare Provider Details

I. General information

NPI: 1053159491
Provider Name (Legal Business Name): OGOCHUKWU JIDECHUKWU SOKUNBI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OGOCHUKWU JIDECHUKWU ELUMELU

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-2146
  • Fax:
Mailing address:
  • Phone: 857-565-5453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3015839
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: