Provider Demographics
NPI:1558393017
Name:UGOCHUKU, IFEANYI (MD)
Entity Type:Individual
Prefix:
First Name:IFEANYI
Middle Name:
Last Name:UGOCHUKU
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 1:1881 COMMERCENTER E
Mailing Address - Street 2:STE 118
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3442
Mailing Address - Country:US
Mailing Address - Phone:909-890-1880
Mailing Address - Fax:
Practice Address - Street 1:1881 COMMERCENTER E
Practice Address - Street 2:STE 118
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3442
Practice Address - Country:US
Practice Address - Phone:909-890-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86654208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G866540Medicaid
CA00G866540Medicaid
CAG79436Medicare UPIN