Provider Demographics
NPI:1487008793
Name:MBAWUIKE, PRIMUS (MD)
Entity Type:Individual
Prefix:DR
First Name:PRIMUS
Middle Name:
Last Name:MBAWUIKE
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 1:13200 CHENAL PKWY
Mailing Address - Street 2:APT 221
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-5388
Mailing Address - Country:US
Mailing Address - Phone:314-210-2075
Mailing Address - Fax:
Practice Address - Street 1:201 N CLIFTON ST
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-3026
Practice Address - Country:US
Practice Address - Phone:870-352-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-13277207P00000X, 208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program