Provider Demographics
NPI:1871852822
Name:NDUBUIZU, KELECHI NNEKA (MD)
Entity Type:Individual
Prefix:DR
First Name:KELECHI
Middle Name:NNEKA
Last Name:NDUBUIZU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:704-867-2134
Practice Address - Street 1:111 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4343
Practice Address - Country:US
Practice Address - Phone:704-874-3300
Practice Address - Fax:704-874-0065
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC183549OtherRTL RESIDENT TRAINING LICENSE
NCAC5385578-R823OtherDEA