Provider Demographics
NPI:1417984063
Name:NWAKANMA, CHUCK G
Entity Type:Individual
Prefix:DR
First Name:CHUCK
Middle Name:G
Last Name:NWAKANMA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:CHUKWUEMEKA
Other - Middle Name:G
Other - Last Name:NWAKANMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1234 E. DUPONT RD.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9728
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:2200 RANDALLIA DR.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4738
Practice Address - Country:US
Practice Address - Phone:260-373-6315
Practice Address - Fax:260-373-6348
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104042207RC0200X
MI4301082608207RC0200X
MO2006015249207RC0200X
IN01067430A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000635990OtherANTHEM
IN000000772101OtherBCBS
IN200962220Medicaid
INP00803485OtherR.R. MEDICARE
IN000000772101OtherBCBS
IN200962220Medicaid
INP00803485OtherR.R. MEDICARE