Healthcare Provider Details

I. General information

NPI: 1962961805
Provider Name (Legal Business Name): IKENNA BEN NWACHUKU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E CHEVY CHASE DR STE 204
GLENDALE CA
91206-4199
US

IV. Provider business mailing address

1500 E CHEVY CHASE DR STE 204
GLENDALE CA
91206-4199
US

V. Phone/Fax

Practice location:
  • Phone: 818-827-3897
  • Fax:
Mailing address:
  • Phone: 818-827-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA181903
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA181903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: