Provider Demographics
NPI:1215216577
Name:IGBOKWE, PROMISE UCHEGBULAM (CLINICIAN)
Entity Type:Individual
Prefix:
First Name:PROMISE
Middle Name:UCHEGBULAM
Last Name:IGBOKWE
Suffix:
Gender:M
Credentials:CLINICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PLEASANT HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2814
Mailing Address - Country:US
Mailing Address - Phone:617-296-7846
Mailing Address - Fax:617-296-7846
Practice Address - Street 1:10 PLEASANT HILL AVE
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2814
Practice Address - Country:US
Practice Address - Phone:617-296-7846
Practice Address - Fax:617-296-7846
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1346486529OtherPRIORITY PROFESSIONAL CARE