Provider Demographics
NPI:1780874776
Name:WINDHAM PRIMARY CARE LLC
Entity type:Organization
Organization Name:WINDHAM PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OBINNA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MADUKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-456-1279
Mailing Address - Street 1:387 TUCKIE RD STE C
Mailing Address - Street 2:
Mailing Address - City:NORTH WINDHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06256-1355
Mailing Address - Country:US
Mailing Address - Phone:860-456-1279
Mailing Address - Fax:860-456-1298
Practice Address - Street 1:387 TUCKIE RD STE C
Practice Address - Street 2:
Practice Address - City:NORTH WINDHAM
Practice Address - State:CT
Practice Address - Zip Code:06256-1355
Practice Address - Country:US
Practice Address - Phone:860-456-1279
Practice Address - Fax:860-456-1298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0375182080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty