Provider Demographics
NPI:1588991855
Name:OKUMAGBA, ENANORE E (MD)
Entity type:Individual
Prefix:DR
First Name:ENANORE
Middle Name:E
Last Name:OKUMAGBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 N. MERIDIAN STREET
Mailing Address - Street 2:PROVIDER ENROLLMENT SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:317-962-4944
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:5751 UNIVERSITY AVE
Practice Address - Street 2:#108 BOX 410
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-7222
Practice Address - Country:US
Practice Address - Phone:317-927-1761
Practice Address - Fax:407-767-0750
Is Sole Proprietor?:No
Enumeration Date:2009-11-07
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01946207R00000X, 208M00000X
IN01069813207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201026800Medicaid
IN000000723422OtherANTHEM PIN
FL148P3OtherBLUE CROSS OF FL
INM400050772Medicare PIN