Provider Demographics
NPI:1588913552
Name:OFOEGBU, KIMBERLY
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:OFOEGBU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EAST HAYESTOWN RD. UNIT 20
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811
Mailing Address - Country:US
Mailing Address - Phone:570-977-1056
Mailing Address - Fax:
Practice Address - Street 1:79 SAND PIT RD STE 102
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4010
Practice Address - Country:US
Practice Address - Phone:718-920-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3657363AM0700X
NY015809363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1588913551Medicaid