Healthcare Provider Details

I. General information

NPI: 1932635372
Provider Name (Legal Business Name): BIENVENU SONGO NZINGA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 12/12/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 S MATTIS AVE
CHAMPAIGN IL
61821-5923
US

IV. Provider business mailing address

611 W. PARK ST FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-2855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.151405
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: