Provider Demographics
NPI:1174821615
Name:KINGSLEY O. OFOEGBU, MD, F.A.C.P., INC.
Entity Type:Organization
Organization Name:KINGSLEY O. OFOEGBU, MD, F.A.C.P., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KINGSLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:OFOEGBU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-484-2420
Mailing Address - Street 1:1711 W TEMPLE ST
Mailing Address - Street 2:SUITE 6644
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5421
Mailing Address - Country:US
Mailing Address - Phone:213-484-2420
Mailing Address - Fax:213-484-2578
Practice Address - Street 1:1711 W TEMPLE ST
Practice Address - Street 2:SUITE 6644
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5421
Practice Address - Country:US
Practice Address - Phone:213-484-2420
Practice Address - Fax:213-484-2578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73040207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA73040Medicare PIN