Provider Demographics
NPI:1861841454
Name:NKOMO, RUTENDO
Entity Type:Individual
Prefix:DR
First Name:RUTENDO
Middle Name:
Last Name:NKOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6751
Mailing Address - Country:US
Mailing Address - Phone:618-463-0649
Mailing Address - Fax:618-465-3390
Practice Address - Street 1:4 MEMORIAL DR STE 210
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6751
Practice Address - Country:US
Practice Address - Phone:618-463-0649
Practice Address - Fax:618-465-3390
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.069063208000000X
IL036149842208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics