Provider Demographics
NPI:1134422355
Name:IWUANYANWU, CHISOM (OD)
Entity type:Individual
Prefix:
First Name:CHISOM
Middle Name:
Last Name:IWUANYANWU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 14 MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1726
Mailing Address - Country:US
Mailing Address - Phone:718-978-0100
Mailing Address - Fax:
Practice Address - Street 1:217 14 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-1726
Practice Address - Country:US
Practice Address - Phone:718-978-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007637-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03556163Medicaid