Healthcare Provider Details

I. General information

NPI: 1003260019
Provider Name (Legal Business Name): IFEANYI VICTOR NWADUKWE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5481 W WATERS AVE STE 111
TAMPA FL
33634-1256
US

IV. Provider business mailing address

5481 W WATERS AVE STE 111
TAMPA FL
33634-1256
US

V. Phone/Fax

Practice location:
  • Phone: 813-577-4686
  • Fax:
Mailing address:
  • Phone: 813-577-4686
  • Fax: 813-577-4694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number37640
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number37640
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: