Provider Demographics
NPI:1639220213
Name:OFORDEME, KENECHUKWU (MD)
Entity type:Individual
Prefix:
First Name:KENECHUKWU
Middle Name:
Last Name:OFORDEME
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 1:655 W 8TH ST # C506
Mailing Address - Street 2:CLINICAL CENTER, 1ST FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-244-3837
Mailing Address - Fax:904-244-4508
Practice Address - Street 1:655 W 8TH ST # C506
Practice Address - Street 2:CLINICAL CENTER, 1ST FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3837
Practice Address - Fax:904-244-4508
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN9215207P00000X
TXN1404207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202491101Medicaid
TX8L4724Medicare Oscar/Certification
TX202491101Medicaid