Provider Demographics
NPI:1306401542
Name:ODELUGO, CHETACHI E (DO)
Entity Type:Individual
Prefix:
First Name:CHETACHI
Middle Name:E
Last Name:ODELUGO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 UNDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-3012
Mailing Address - Country:US
Mailing Address - Phone:862-899-2231
Mailing Address - Fax:
Practice Address - Street 1:81 UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-3012
Practice Address - Country:US
Practice Address - Phone:862-899-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.164650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program