Basic Information
| Provider Information | |||||||||
| NPI: | 1306848080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDOKWE | ||||||||
| FirstName: | OBUNIKE | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 W GILBERT ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077014918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7212120060 | ||||||||
| FaxNumber: | 7322120061 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 N 13TH ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071071317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732681400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 01/31/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA05586100 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2492601 | 05 | NJ | MEDICAID |