Provider Demographics
NPI:1811294952
Name:IFEOMA S IZUCHUKWU MD, A PROF MED CORP
Entity type:Organization
Organization Name:IFEOMA S IZUCHUKWU MD, A PROF MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IFEOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:IZUCHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-664-1121
Mailing Address - Street 1:PO BOX 13042
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90295-4042
Mailing Address - Country:US
Mailing Address - Phone:888-664-1121
Mailing Address - Fax:310-362-0390
Practice Address - Street 1:8540 S SEPULVEDA BLVD
Practice Address - Street 2:STE 116
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3807
Practice Address - Country:US
Practice Address - Phone:888-664-1121
Practice Address - Fax:310-362-0390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty