Provider Demographics
NPI:1083765481
Name:OJUKWU, MBANEFO (MD)
Entity Type:Individual
Prefix:
First Name:MBANEFO
Middle Name:
Last Name:OJUKWU
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 1:147 MALLARD CREEK RUN
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:OH
Mailing Address - Zip Code:44050-9803
Mailing Address - Country:US
Mailing Address - Phone:440-458-5827
Mailing Address - Fax:
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5293
Practice Address - Country:US
Practice Address - Phone:440-835-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.081482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2510885Medicaid
OHOJ4129901Medicare ID - Type Unspecified