Provider Demographics
NPI:1235309352
Name:OKAGBUE, REGINALD NNAMDI (MD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:NNAMDI
Last Name:OKAGBUE
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 1:5736 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-4152
Mailing Address - Country:US
Mailing Address - Phone:773-385-9850
Mailing Address - Fax:773-385-9850
Practice Address - Street 1:5736 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-4152
Practice Address - Country:US
Practice Address - Phone:773-385-9850
Practice Address - Fax:773-385-9850
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095405Medicaid
IL036095405Medicaid
IL578570Medicare PIN