Basic Information
| Provider Information | |||||||||
| NPI: | 1588991855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OKUMAGBA | ||||||||
| FirstName: | ENANORE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N. MERIDIAN STREET | ||||||||
| Address2: | PROVIDER ENROLLMENT SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462043908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179624944 | ||||||||
| FaxNumber: | 3179624950 | ||||||||
| Practice Location | |||||||||
| Address1: | 5751 UNIVERSITY AVE | ||||||||
| Address2: | #108 BOX 410 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462197222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179271761 | ||||||||
| FaxNumber: | 4077670750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2009 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2009-01946 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2009-01946 | NC | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 01069813 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201026800 | 05 | IN | MEDICAID | 000000723422 | 01 | IN | ANTHEM PIN | OTHER | 148P3 | 01 | FL | BLUE CROSS OF FL | OTHER |