Provider Demographics
NPI:1902429467
Name:IJEOKWU, RAPHAEL
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:IJEOKWU
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 1:2107 E 72ND PL APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-6080
Mailing Address - Country:US
Mailing Address - Phone:312-975-5928
Mailing Address - Fax:
Practice Address - Street 1:541 N WILLIAMS ST FL 1
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:IL
Practice Address - Zip Code:60476-1018
Practice Address - Country:US
Practice Address - Phone:312-975-5928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85110144Medicaid