Provider Demographics
NPI:1376151472
Name:CHUKWUOCHA, CANICE (MD)
Entity Type:Individual
Prefix:DR
First Name:CANICE
Middle Name:
Last Name:CHUKWUOCHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 OLD MOULTRIE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4198
Mailing Address - Country:US
Mailing Address - Phone:904-293-0299
Mailing Address - Fax:
Practice Address - Street 1:264A PALM COAST PKWY NE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8217
Practice Address - Country:US
Practice Address - Phone:386-446-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1489208D00000X
PR021723208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice