Healthcare Provider Details

I. General information

NPI: 1487279824
Provider Name (Legal Business Name): NSISONGIKANABASI MFON UDOH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST BLDG 502
HARTFORD CT
06102-8000
US

IV. Provider business mailing address

6425 S LOWE AVE APT 513
CHICAGO IL
60621-2726
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-0549
  • Fax: 860-545-5221
Mailing address:
  • Phone: 773-251-3585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number76284
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number76284
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: