Healthcare Provider Details

I. General information

NPI: 1497002471
Provider Name (Legal Business Name): FORTUNE EGBULEFU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-3040
  • Fax:
Mailing address:
  • Phone: 702-653-3040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number20444
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: