Provider Demographics
NPI:1134239932
Name:OKONKWOAGUOLU, JERRY AZUBUIKE (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:AZUBUIKE
Last Name:OKONKWOAGUOLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEREMIAH
Other - Middle Name:A O
Other - Last Name:AGUOLU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-0425
Mailing Address - Country:US
Mailing Address - Phone:310-644-4488
Mailing Address - Fax:310-679-4035
Practice Address - Street 1:15603 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2639
Practice Address - Country:US
Practice Address - Phone:310-644-4488
Practice Address - Fax:310-679-4035
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29427207Q00000X, 207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA294270Medicaid
CAA294270Medicaid
CAWA29427FMedicare PIN