Provider Demographics
NPI:1285732354
Name:OFOEGBU, KINGSLEY (MD)
Entity type:Individual
Prefix:DR
First Name:KINGSLEY
Middle Name:
Last Name:OFOEGBU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 E REGENT ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1433
Mailing Address - Country:US
Mailing Address - Phone:310-674-5353
Mailing Address - Fax:310-674-7041
Practice Address - Street 1:644 E REGENT ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1433
Practice Address - Country:US
Practice Address - Phone:310-674-5353
Practice Address - Fax:310-674-7041
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A730400Medicaid
CAA73040Medicare ID - Type Unspecified
CA00A730400Medicaid