Provider Demographics
NPI: | 1619934320 |
---|---|
Name: | ODUMODU, NWANNEKA U (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | NWANNEKA |
Middle Name: | U |
Last Name: | ODUMODU |
Suffix: | |
Gender: | F |
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: | 16184 E 10 MILE RD STE 101 |
Mailing Address - Street 2: | |
Mailing Address - City: | EASTPOINTE |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48021-1160 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 586-779-4550 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 16184 E 10 MILE RD STE 101 |
Practice Address - Street 2: | |
Practice Address - City: | EASTPOINTE |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48021 |
Practice Address - Country: | US |
Practice Address - Phone: | 586-779-4550 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-27 |
Last Update Date: | 2018-05-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 4301077637 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
080H262390 | Other | BLUE CROSS-BLUE CROSS | |
MI | 478692310 | Medicaid | |
NO077637 | Other | CHAMPUS-CHAMPUS | |
NO077637 | Other | COMMERCIAL-COMMERCIAL NUMBER | |
MI | 478692310 | Medicaid | |
080H262390 | Other | BLUE CROSS-BLUE CROSS |