Healthcare Provider Details

I. General information

NPI: 1619402682
Provider Name (Legal Business Name): MR. AUGUSTINE CHIKE OKONKWO-AGBOJE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 E 149TH ST FL 4
BRONX NY
10451-5601
US

IV. Provider business mailing address

329 E 149TH ST FL 4
BRONX NY
10451-5601
US

V. Phone/Fax

Practice location:
  • Phone: 718-769-2698
  • Fax: 718-401-0108
Mailing address:
  • Phone: 718-769-2698
  • Fax: 718-401-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: