Healthcare Provider Details

I. General information

NPI: 1780909713
Provider Name (Legal Business Name): CHINENYE OGOMA IWUCHUKWU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

504 CLINTON CENTER DRIVE CBO - SUITE 4300
CLINTON MS
39056
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-2005
  • Fax:
Mailing address:
  • Phone: 601-815-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number25974
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number01092168A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number25974
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25974
License Number StateMS
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01092168A
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMC-2842
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: