Healthcare Provider Details

I. General information

NPI: 1790313260
Provider Name (Legal Business Name): IKECHUKWU CHIDOBEM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 W HAMMER LN
STOCKTON CA
95209-2839
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-4795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA206584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: