Healthcare Provider Details

I. General information

NPI: 1003069766
Provider Name (Legal Business Name): IJEOMA NNODIM OPARA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 ST. ANTOINE STE 6A & 6B GENERAL MEDICINE AMBULATORY PRACTICE
DETROIT MI
48201-1804
US

IV. Provider business mailing address

400 MACK AVE STE 2
DETROIT MI
48201-2136
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4627
  • Fax: 313-966-7305
Mailing address:
  • Phone: 313-448-9006
  • Fax: 313-966-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301092567
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301092567
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: