Provider Demographics
NPI:1720603145
Name:NWACHUKWU, IFEDIBA ADOULPHOUS (MD)
Entity Type:Individual
Prefix:DR
First Name:IFEDIBA
Middle Name:ADOULPHOUS
Last Name:NWACHUKWU
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 1:6017 MADISON STREET
Mailing Address - Street 2:APT 3R
Mailing Address - City:RIEGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:718-314-1029
Mailing Address - Fax:
Practice Address - Street 1:800 STANTON L YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5018
Practice Address - Country:US
Practice Address - Phone:405-271-6173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2023-05-29
Deactivation Date:2022-01-18
Deactivation Code:
Reactivation Date:2022-02-15
Provider Licenses
StateLicense IDTaxonomies
OK0000000207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program