Provider Demographics
NPI:1225075708
Name:RICHARDSON, NWANNEKA (MBBS)
Entity Type:Individual
Prefix:DR
First Name:NWANNEKA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BURNHAM AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-3401
Mailing Address - Country:US
Mailing Address - Phone:708-862-0305
Mailing Address - Fax:
Practice Address - Street 1:510 BURNHAM AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-3401
Practice Address - Country:US
Practice Address - Phone:708-862-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1027192080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-102719Medicaid
ILH25529Medicare UPIN