Healthcare Provider Details

I. General information

NPI: 1962166686
Provider Name (Legal Business Name): JUDE NNAMDI IZUKA SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W 38TH ST FL 6
NEW YORK NY
10018-9537
US

IV. Provider business mailing address

4104 HILL AVE
BRONX NY
10466-2106
US

V. Phone/Fax

Practice location:
  • Phone: 212-695-4564
  • Fax:
Mailing address:
  • Phone: 212-316-3828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: