Healthcare Provider Details

I. General information

NPI: 1275791451
Provider Name (Legal Business Name): JOSEPHINE MOKONOGHO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2008
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD DEPARTMENT OF PSYCHIATRY
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

501 W 14TH ST STE 1E40
WILMINGTON DE
19801-1013
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4551
  • Fax:
Mailing address:
  • Phone: 302-320-2100
  • Fax: 302-320-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC1-0013564
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberMD 442619
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberC1-0013564
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: