Provider Demographics
NPI:1649407487
Name:IFEANYI, CHUKA VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:CHUKA
Middle Name:VICTOR
Last Name:IFEANYI
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 1:1455 E BERT KOUN LOOP
Mailing Address - Street 2:#206
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4464
Mailing Address - Fax:318-798-4529
Practice Address - Street 1:1455 E BERT KOUN LOOP
Practice Address - Street 2:#206
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4464
Practice Address - Fax:318-798-4529
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8725207Y00000X
LA206975207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2370146Medicaid
LA360016YJS0Medicare PIN