MEDICARE: DR. ENANORE E OKUMAGBA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2009-01946	NC
2	208M00000X	Hospitalist Physician	2009-01946	NC
3	207R00000X	Internal Medicine Physician	01069813	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000723422	OTHER	IN	ANTHEM PIN
3	148P3	OTHER	FL	BLUE CROSS OF FL

General Provider Information

NPI Number	:	1588991855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ENANORE E OKUMAGBA M.D.

Provider Business Mailing Address
First Line	:	950 N. MERIDIAN STREET
Second Line	:	PROVIDER ENROLLMENT SUITE 500
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-3908
Country	:	US
Telephone Number	:	317-962-4944
Fax Number	:	317-962-4950

Provider Business Practice Location Address
First Line	:	5751 UNIVERSITY AVE
Second Line	:	#108 BOX 410
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-7222
Country	:	US
Telephone Number	:	317-927-1761
Fax Number	:	407-767-0750

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2009
Last Update Date	:	12/06/2011

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