1811294952 NPI number — IFEOMA S IZUCHUKWU MD, A PROF MED CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811294952 NPI number — IFEOMA S IZUCHUKWU MD, A PROF MED CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IFEOMA S IZUCHUKWU MD, A PROF MED CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811294952
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13042
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARINA DEL REY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90295-4042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-664-1121
Provider Business Mailing Address Fax Number:
310-362-0390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8540 S SEPULVEDA BLVD
Provider Second Line Business Practice Location Address:
STE 116
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90045-3807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-664-1121
Provider Business Practice Location Address Fax Number:
310-362-0390
Provider Enumeration Date:
02/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
IZUCHUKWU
Authorized Official First Name:
IFEOMA
Authorized Official Middle Name:
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
888-664-1121

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A80750 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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