=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144210717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES C. UGOKWE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2005
-----------------------------------------------------
Last Update Date | 09/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2223 WORLEY DR
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-473-0773
-----------------------------------------------------
Fax | 318-473-0836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12911
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71315-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-473-0773
-----------------------------------------------------
Fax | 318-473-0836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204D00000X
-----------------------------------------------------
Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
-----------------------------------------------------
License Number | 13814R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 13814R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------