Provider Demographics
NPI:1619509809
Name:IGBINEWEKA, OMOROGBE NORENSE
Entity Type:Individual
Prefix:
First Name:OMOROGBE
Middle Name:NORENSE
Last Name:IGBINEWEKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1018
Mailing Address - Country:US
Mailing Address - Phone:510-860-6726
Mailing Address - Fax:
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1018
Practice Address - Country:US
Practice Address - Phone:510-437-7396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA824217163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA824217OtherRN LICENSE