Healthcare Provider Details

I. General information

NPI: 1043070725
Provider Name (Legal Business Name): OGOEGBUNAM OKOLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

147 W 111TH ST APT 5
NEW YORK NY
10026-4261
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-4000
  • Fax:
Mailing address:
  • Phone: 216-338-6036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: