Provider Demographics
NPI:1568080448
Name:CHUKWU, CHISOHLM
Entity Type:Individual
Prefix:
First Name:CHISOHLM
Middle Name:
Last Name:CHUKWU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2881
Mailing Address - Country:US
Mailing Address - Phone:623-332-7525
Mailing Address - Fax:
Practice Address - Street 1:10900 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44106-1712
Practice Address - Country:US
Practice Address - Phone:623-332-7525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.0042741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHVE071540OtherDRIVERS LICENSE