Provider Demographics
NPI:1205306693
Name:OBEGOLU, CHIDUBEM MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:CHIDUBEM
Middle Name:MATTHEW
Last Name:OBEGOLU
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 1:10815 SEAVIEW AVE APT 40B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4682
Mailing Address - Country:US
Mailing Address - Phone:817-217-4412
Mailing Address - Fax:
Practice Address - Street 1:9131 175TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5517
Practice Address - Country:US
Practice Address - Phone:718-657-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP14162208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice