Healthcare Provider Details

I. General information

NPI: 1003705617
Provider Name (Legal Business Name): IKECHUKWU MGBUDEM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OAKLAND INTEGRATED HEALTH CARE NETWORK DBA HONOR COMMUN 461 WEST HURON STREET, SUITE 107
PONTIAC MI
48341-0150
US

IV. Provider business mailing address

PO BOX 430150
PONTIAC MI
48343-0150
US

V. Phone/Fax

Practice location:
  • Phone: 248-724-7600
  • Fax: 248-857-7141
Mailing address:
  • Phone: 248-724-7600
  • Fax: 248-857-7141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351055089
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: