Provider Demographics
NPI:1992029987
Name:OGBUAGU, HENRY M (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:M
Last Name:OGBUAGU
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 1:4500 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5360
Mailing Address - Country:US
Mailing Address - Phone:618-257-6220
Mailing Address - Fax:
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:618-257-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA90333207R00000X, 208M00000X
IL036164945207R00000X, 208M00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSSN