Healthcare Provider Details

I. General information

NPI: 1629604574
Provider Name (Legal Business Name): IKENNA NDUBUISI NWOSU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2020
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 S ELM AVE
FRESNO CA
93706-5435
US

IV. Provider business mailing address

2740 S ELM AVE
FRESNO CA
93706-5435
US

V. Phone/Fax

Practice location:
  • Phone: 559-457-5200
  • Fax: 559-457-5296
Mailing address:
  • Phone: 559-457-5200
  • Fax: 559-457-5296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA182752
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: