Healthcare Provider Details

I. General information

NPI: 1992090112
Provider Name (Legal Business Name): ONYEKACHI OGBONNA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 NW 22ND AVE
PORTLAND OR
97210-2900
US

IV. Provider business mailing address

1130 NW 22ND AVE
PORTLAND OR
97210-2900
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-8470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD460052
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD198478
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: