Healthcare Provider Details

I. General information

NPI: 1386265445
Provider Name (Legal Business Name): NNEKA IFEOMA OGBUTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 PARK AVE # WP1-200
TRUMBULL CT
06611-3463
US

IV. Provider business mailing address

246 MARYLAND AVE
FREEPORT NY
11520-1015
US

V. Phone/Fax

Practice location:
  • Phone: 203-666-3750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number80328
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number80328
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: