Provider Demographics
NPI:1982623179
Name:NDIFORCHU, FOMBE (MD)
Entity Type:Individual
Prefix:DR
First Name:FOMBE
Middle Name:
Last Name:NDIFORCHU
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 1:454 E CARSON PLAZA DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3209
Mailing Address - Country:US
Mailing Address - Phone:310-516-0742
Mailing Address - Fax:310-516-9158
Practice Address - Street 1:454 E CARSON PLAZA DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3209
Practice Address - Country:US
Practice Address - Phone:310-516-0742
Practice Address - Fax:310-516-9158
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA267212086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A267210Medicaid
A83428Medicare UPIN