Provider Demographics
NPI:1710035126
Name:MGBOJIRIKWE, THECLA N (MD)
Entity Type:Individual
Prefix:DR
First Name:THECLA
Middle Name:N
Last Name:MGBOJIRIKWE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THECLA
Other - Middle Name:N
Other - Last Name:IKEDUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:936 N WILMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4102
Mailing Address - Country:US
Mailing Address - Phone:310-816-3111
Mailing Address - Fax:
Practice Address - Street 1:936 N WILMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-4102
Practice Address - Country:US
Practice Address - Phone:310-816-3111
Practice Address - Fax:310-816-3116
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83572174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0098551Medicare ID - Type UnspecifiedGROUP MEDICAL NUMBER