Provider Demographics
NPI:1699419747
Name:OGBONNA, MICHAEL OGBONNA IKECHI
Entity type:Individual
Prefix:
First Name:MICHAEL OGBONNA
Middle Name:IKECHI
Last Name:OGBONNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3093 BROADWAY UNIT 684
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5957
Mailing Address - Country:US
Mailing Address - Phone:214-232-6213
Mailing Address - Fax:
Practice Address - Street 1:3093 BROADWAY UNIT 684
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5957
Practice Address - Country:US
Practice Address - Phone:214-232-6213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program