Provider Demographics
NPI:1710065917
Name:MADUKA, OBINNA I (MD)
Entity Type:Individual
Prefix:
First Name:OBINNA
Middle Name:I
Last Name:MADUKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OBINNA
Other - Middle Name:
Other - Last Name:MADUKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:387 TUCKIE RD STE C
Mailing Address - Street 2:
Mailing Address - City:NORTH WINDHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06256-1355
Mailing Address - Country:US
Mailing Address - Phone:860-456-1279
Mailing Address - Fax:860-456-1298
Practice Address - Street 1:387 TUCKIE RD STE C
Practice Address - Street 2:
Practice Address - City:NORTH WINDHAM
Practice Address - State:CT
Practice Address - Zip Code:06256-1355
Practice Address - Country:US
Practice Address - Phone:860-456-1279
Practice Address - Fax:860-456-1298
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037518208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001375189Medicaid
CTF49845Medicare UPIN