Healthcare Provider Details

I. General information

NPI: 1134124001
Provider Name (Legal Business Name): CHUKWUEMEKA NDULUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 SPRUCE ST
GRIDLEY CA
95948-2239
US

IV. Provider business mailing address

135 SPRUCE ST
GRIDLEY CA
95948-2239
US

V. Phone/Fax

Practice location:
  • Phone: 530-846-1400
  • Fax: 530-846-4762
Mailing address:
  • Phone: 530-846-1400
  • Fax: 530-846-4762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA48878
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRHM53931F
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: