Healthcare Provider Details

I. General information

NPI: 1760672497
Provider Name (Legal Business Name): CHUKWUDI EMMANUEL NWODO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DR
LEBANON MO
65536-9210
US

IV. Provider business mailing address

4428 E AMBROSE DR
SPRINGFIELD MO
65802-2446
US

V. Phone/Fax

Practice location:
  • Phone: 417-533-6350
  • Fax:
Mailing address:
  • Phone: 302-465-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010019787
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: