Provider Demographics
NPI:1417021296
Name:CHUKWURAH, LOUIS MBANEFO
Entity Type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:MBANEFO
Last Name:CHUKWURAH
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 1:81 MADDOX RD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3652
Mailing Address - Country:US
Mailing Address - Phone:770-614-8557
Mailing Address - Fax:770-614-8717
Practice Address - Street 1:81 MADDOX RD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3652
Practice Address - Country:US
Practice Address - Phone:770-614-8557
Practice Address - Fax:770-614-8717
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA06-01-256-9171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4944580004Medicare NSC