Provider Demographics
NPI:1962496307
Name:KOKORICHA, TOBORE GODWIN (MD)
Entity Type:Individual
Prefix:
First Name:TOBORE
Middle Name:GODWIN
Last Name:KOKORICHA
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 1:2001 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4086
Mailing Address - Country:US
Mailing Address - Phone:575-935-1625
Mailing Address - Fax:575-935-1626
Practice Address - Street 1:2001 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4086
Practice Address - Country:US
Practice Address - Phone:575-935-1625
Practice Address - Fax:575-935-1626
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1768748207R00000X
TXR1567207R00000X
NMMD20040599207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72821761Medicaid
I19328Medicare UPIN
NM72821761Medicaid