Healthcare Provider Details

I. General information

NPI: 1225652696
Provider Name (Legal Business Name): UBA CHINYERE UDEH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E DOUGLAS RD STE 309
MISHAWAKA IN
46545-1467
US

IV. Provider business mailing address

5215 HOLY CROSS PKWY
MISHAWAKA IN
46545-1469
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-6900
  • Fax: 574-335-0854
Mailing address:
  • Phone: 574-335-8707
  • Fax: 574-335-0854

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036165483
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT221170
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036165483
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036165483
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01099441A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: