Provider Demographics
NPI:1235463084
Name:IWUNNAH, IKECHUKWU STANISLAUS
Entity Type:Individual
Prefix:MR
First Name:IKECHUKWU
Middle Name:STANISLAUS
Last Name:IWUNNAH
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 1:3201 IH-30 STE C2
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2602
Mailing Address - Country:US
Mailing Address - Phone:972-279-0643
Mailing Address - Fax:972-279-0543
Practice Address - Street 1:3201 IH 30 STE C2
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2602
Practice Address - Country:US
Practice Address - Phone:972-279-0643
Practice Address - Fax:972-279-0543
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0109451171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor