Provider Demographics
NPI:1144083411
Name:OKUNGBOWA, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:OKUNGBOWA
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 1:4533 W 101ST PL
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4217
Mailing Address - Country:US
Mailing Address - Phone:773-656-5628
Mailing Address - Fax:
Practice Address - Street 1:4533 W 101ST PL
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4217
Practice Address - Country:US
Practice Address - Phone:773-656-5628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2025-01-22
Deactivation Date:2024-02-13
Deactivation Code:
Reactivation Date:2025-01-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver