Provider Demographics
NPI:1437230661
Name:IHEMAGUBA, MICHAEL OKECHUKWU (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:OKECHUKWU
Last Name:IHEMAGUBA
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:PO BOX 2784
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-8684
Mailing Address - Country:US
Mailing Address - Phone:347-423-4571
Mailing Address - Fax:718-960-9414
Practice Address - Street 1:1973 UNIVERSITY AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453
Practice Address - Country:US
Practice Address - Phone:718-866-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207150207Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01928463Medicaid
NY01928463Medicaid