Provider Demographics
NPI:1972918738
Name:OMEKANDA, JEAN-LUCIEN (MD)
Entity type:Individual
Prefix:DR
First Name:JEAN-LUCIEN
Middle Name:
Last Name:OMEKANDA
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:3003 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4110
Practice Address - Country:US
Practice Address - Phone:715-735-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105183207R00000X
WI84985-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100300024Medicaid