Provider Demographics
NPI:1083608350
Name:DOKUBO, IGONI INKO (MD)
Entity Type:Individual
Prefix:DR
First Name:IGONI
Middle Name:INKO
Last Name:DOKUBO
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 1:3435 W VAN BUREN ST
Mailing Address - Street 2:SUITE 028
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-3312
Mailing Address - Country:US
Mailing Address - Phone:773-265-0200
Mailing Address - Fax:773-265-8386
Practice Address - Street 1:3435 W VAN BUREN ST
Practice Address - Street 2:SUITE 028
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-3312
Practice Address - Country:US
Practice Address - Phone:773-265-0200
Practice Address - Fax:773-265-8386
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371650Medicare ID - Type Unspecified
ILG14002Medicare UPIN