Provider Demographics
NPI:1356661433
Name:NWANKWO, UGONNA THOMAS ANTOINE (MD)
Entity Type:Individual
Prefix:DR
First Name:UGONNA
Middle Name:THOMAS ANTOINE
Last Name:NWANKWO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:UGO
Other - Middle Name:THOMAS
Other - Last Name:NWANKWO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-577-5633
Mailing Address - Fax:314-268-4141
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5380
Practice Address - Fax:314-268-4141
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT197261208000000X, 2080P0202X, 207R00000X
IL0361470642080P0202X
MO20200419282080P0202X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine