Healthcare Provider Details

I. General information

NPI: 1285438390
Provider Name (Legal Business Name): CHIBUZOR EMMANUEL ODIGILI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W COVENTRY CT
MILWAUKEE WI
53217-3971
US

IV. Provider business mailing address

303 W COVENTRY CT
MILWAUKEE WI
53217-3971
US

V. Phone/Fax

Practice location:
  • Phone: 414-210-1725
  • Fax:
Mailing address:
  • Phone: 414-210-1725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number00005512
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: