Healthcare Provider Details

I. General information

NPI: 1427509751
Provider Name (Legal Business Name): MEDICINE AND NEPHROLOGY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W CENTRAL AVE STE 206
EL DORADO KS
67042-2186
US

IV. Provider business mailing address

700 W CENTRAL AVE STE 206
EL DORADO KS
67042-2186
US

V. Phone/Fax

Practice location:
  • Phone: 316-452-5455
  • Fax: 316-321-0503
Mailing address:
  • Phone: 316-452-5455
  • Fax: 316-321-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NDUBUEZE FIDELIS OKONKWO
Title or Position: OWNER
Credential: M.D
Phone: 316-452-5455