Provider Demographics
NPI:1508354432
Name:AYETIN, CHUKWUKA G (DO)
Entity Type:Individual
Prefix:
First Name:CHUKWUKA
Middle Name:G
Last Name:AYETIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 SUNFOREST DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6327
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:813-514-8891
Practice Address - Street 1:605 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3211
Practice Address - Country:US
Practice Address - Phone:352-796-9990
Practice Address - Fax:352-796-2226
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17378207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110907100Medicaid
FL110907100Medicaid