Provider Demographics
NPI:1417513409
Name:NDUKWE, STEPHEN (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:NDUKWE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6471 ANNA DR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5254
Mailing Address - Country:US
Mailing Address - Phone:734-837-6660
Mailing Address - Fax:
Practice Address - Street 1:3999 VENOY RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1485
Practice Address - Country:US
Practice Address - Phone:734-727-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001943208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation