Provider Demographics
NPI:1548571888
Name:MKPOLULU, CHIEDOZIE (MD)
Entity Type:Individual
Prefix:
First Name:CHIEDOZIE
Middle Name:
Last Name:MKPOLULU
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 1:734 N 3RD ST STE 115
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5287
Mailing Address - Country:US
Mailing Address - Phone:352-365-2757
Mailing Address - Fax:
Practice Address - Street 1:801 E DIXIE AVE STE 104
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7601
Practice Address - Country:US
Practice Address - Phone:352-787-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128479207U00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine