Healthcare Provider Details

I. General information

NPI: 1295770436
Provider Name (Legal Business Name): ENI CLEMENT OKONOFUA M.B.,B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5390 DORCHESTER RD
NORTH CHARLESTON SC
29418-5652
US

IV. Provider business mailing address

5390 DORCHESTER RD
N CHARLESTON SC
29418-5652
US

V. Phone/Fax

Practice location:
  • Phone: 843-552-3099
  • Fax: 846-559-9037
Mailing address:
  • Phone: 843-552-3099
  • Fax: 843-552-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number21076
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: