Healthcare Provider Details

I. General information

NPI: 1477129062
Provider Name (Legal Business Name): VIVIAN NNENNA CHUKWUMA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date: 04/03/2023
Reactivation Date: 06/22/2023

III. Provider practice location address

4220 WEST 95TH STREET SUITE 200
OAK LAWN IL
60453
US

IV. Provider business mailing address

4220 WEST 95TH STREET SUITE 200
OAK LAWN IL
60453
US

V. Phone/Fax

Practice location:
  • Phone: 708-398-0287
  • Fax: 708-684-2032
Mailing address:
  • Phone: 708-398-0287
  • Fax: 708-684-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.077859
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: