Provider Demographics
NPI:1841441896
Name:CHUKWUMA J. UDEH, MD INC.
Entity type:Organization
Organization Name:CHUKWUMA J. UDEH, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUKWUMA
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:UDEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-882-7554
Mailing Address - Street 1:399 E HIGHLAND AVE STE 415
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3815
Mailing Address - Country:US
Mailing Address - Phone:909-882-7554
Mailing Address - Fax:909-882-6511
Practice Address - Street 1:399 E HIGHLAND AVE STE 415
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3815
Practice Address - Country:US
Practice Address - Phone:909-882-7554
Practice Address - Fax:909-882-6511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G460741261QA0005X
CA00G460740261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G460740Medicaid
CA00G460741Medicaid
CA00G460740Medicaid