Provider Demographics
NPI:1992238760
Name:SOGBODJOR, AMORKOR
Entity type:Individual
Prefix:
First Name:AMORKOR
Middle Name:
Last Name:SOGBODJOR
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 1:4775 E MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-8820
Mailing Address - Country:US
Mailing Address - Phone:217-864-3737
Mailing Address - Fax:
Practice Address - Street 1:4775 E MARYLAND ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-8820
Practice Address - Country:US
Practice Address - Phone:217-864-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036167087207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036167087OtherMD LICENSE