Healthcare Provider Details

I. General information

NPI: 1336273911
Provider Name (Legal Business Name): IFEANYI NWANESHIUDU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 S CAMP MEADE RD STE 1
LINTHICUM HEIGHTS MD
21090-2766
US

IV. Provider business mailing address

518 S CAMP MEADE RD STE 1
LINTHICUM HEIGHTS MD
21090-2766
US

V. Phone/Fax

Practice location:
  • Phone: 267-241-5100
  • Fax:
Mailing address:
  • Phone: 443-410-3325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberD0078360
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC70003460
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: