Healthcare Provider Details

I. General information

NPI: 1811550585
Provider Name (Legal Business Name): ONYINYECHUKWU IGBOKWE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SPRUCE ST 2ND FL AREA 2
ESPANOLA NM
87532-2724
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-0340
  • Fax: 845-647-7632
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2022-0429
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: