Provider Demographics
NPI:1649970278
Name:AGBAI, OKONKWO KALU
Entity type:Individual
Prefix:
First Name:OKONKWO
Middle Name:KALU
Last Name:AGBAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NEWMAN AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5130
Mailing Address - Country:US
Mailing Address - Phone:216-526-2663
Mailing Address - Fax:216-526-2663
Practice Address - Street 1:1441 NEWMAN AVE APT 101
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5130
Practice Address - Country:US
Practice Address - Phone:121-652-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty