=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962296301
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IKPONMWOSA JUDE OGIEUHI M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2025
-----------------------------------------------------
Last Update Date | 01/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4201 MEDICAL CENTER DRIVE
-----------------------------------------------------
City | MCHENRY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-759-4726
-----------------------------------------------------
Fax | 815-759-8255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4201 MEDICAL CENTER DRIVER
-----------------------------------------------------
City | MCHENRY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-403-3905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 125086638
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------