Provider Demographics
NPI:1720448244
Name:KINGSLEY OFOEGBU, MD INC.
Entity Type:Organization
Organization Name:KINGSLEY OFOEGBU, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KINGSLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:OFOEGBU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-674-5353
Mailing Address - Street 1:644 E REGENT ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1433
Mailing Address - Country:US
Mailing Address - Phone:310-674-5353
Mailing Address - Fax:310-330-0665
Practice Address - Street 1:644 E REGENT ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1433
Practice Address - Country:US
Practice Address - Phone:310-674-5353
Practice Address - Fax:310-330-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-25
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A730400Medicaid
CAH53915Medicare UPIN
CAA73040Medicare Oscar/Certification