Provider Demographics
NPI:1861914202
Name:OKWUNDU, CHARLES I (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:I
Last Name:OKWUNDU
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 1:2004 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1299
Mailing Address - Country:US
Mailing Address - Phone:606-248-3015
Mailing Address - Fax:606-248-3024
Practice Address - Street 1:2004 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1299
Practice Address - Country:US
Practice Address - Phone:606-248-3015
Practice Address - Fax:606-248-3024
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP161208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics