Healthcare Provider Details

I. General information

NPI: 1639220213
Provider Name (Legal Business Name): KENECHUKWU OFORDEME M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST # C506 CLINICAL CENTER, 1ST FLOOR
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

655 W 8TH ST # C506 CLINICAL CENTER, 1ST FLOOR
JACKSONVILLE FL
32209-6511
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-3837
  • Fax: 904-244-4508
Mailing address:
  • Phone: 904-244-3837
  • Fax: 904-244-4508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberTRN9215
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberN1404
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: