Provider Demographics
NPI:1619264819
Name:CHUKWUANU, KENECHUKWU A (MD)
Entity Type:Individual
Prefix:
First Name:KENECHUKWU
Middle Name:A
Last Name:CHUKWUANU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KENE
Other - Middle Name:A
Other - Last Name:CHUKWUANU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:#100371
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0301
Mailing Address - Country:US
Mailing Address - Phone:352-265-0301
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:#100371
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0301
Practice Address - Country:US
Practice Address - Phone:352-265-0301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME129240207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018294300Medicaid
FLIR114ZMedicare PIN