Provider Demographics
NPI:1700976065
Name:UDEH, CHUKWUMA JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUKWUMA
Middle Name:JOHN
Last Name:UDEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:399 E HIGHLAND AVE
Mailing Address - Street 2:415
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3808
Mailing Address - Country:US
Mailing Address - Phone:909-882-7554
Mailing Address - Fax:909-882-6511
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:415
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:909-882-7554
Practice Address - Fax:909-882-6511
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA00G460740207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G460740Medicaid
CA00G460740Medicaid