Healthcare Provider Details

I. General information

NPI: 1417349325
Provider Name (Legal Business Name): CHUCK OGBODO PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOSTON MEDICAL CTR PL
BOSTON MA
02118-2908
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FL 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 508-408-9200
  • Fax:
Mailing address:
  • Phone: 617-414-5405
  • Fax: 617-414-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2284675
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: