Provider Demographics
NPI:1508268186
Name:NDUKWE, THEOPHILUS IKECHUKWU
Entity Type:Individual
Prefix:MR
First Name:THEOPHILUS
Middle Name:IKECHUKWU
Last Name:NDUKWE
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:6938 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-1547
Mailing Address - Country:US
Mailing Address - Phone:301-583-0007
Mailing Address - Fax:
Practice Address - Street 1:6856 EASTERN AVE NW STE 220
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-2166
Practice Address - Country:US
Practice Address - Phone:202-291-6973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN1002477164W00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No164W00000XNursing Service ProvidersLicensed Practical Nurse