Provider Demographics
NPI:1841291788
Name:MBONU, IKECHUKWU D (MD)
Entity type:Individual
Prefix:DR
First Name:IKECHUKWU
Middle Name:D
Last Name:MBONU
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 1:7350 VAN DUSEN RD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5267
Mailing Address - Country:US
Mailing Address - Phone:240-294-6677
Mailing Address - Fax:240-294-7645
Practice Address - Street 1:7350 VAN DUSEN RD STE 130
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5267
Practice Address - Country:US
Practice Address - Phone:240-294-6677
Practice Address - Fax:240-294-7645
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD035226207R00000X
MDD0059649207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402755800Medicaid
DC01255IM58Medicare PIN
MD402755800Medicaid
MD623P284HMedicare PIN
MD01255IM58Medicare ID - Type Unspecified
DC137640ZBQLMedicare PIN