Healthcare Provider Details

I. General information

NPI: 1689768525
Provider Name (Legal Business Name): NDUKWE KALU UDUMA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 UNIVERSITY BLVD
TYLER TX
75701-6623
US

IV. Provider business mailing address

11937 US HIGHWAY 271
TYLER TX
75708-3154
US

V. Phone/Fax

Practice location:
  • Phone: 903-594-2450
  • Fax:
Mailing address:
  • Phone: 903-877-7168
  • Fax: 903-877-8355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number238106
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberM5955
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: