Healthcare Provider Details

I. General information

NPI: 1598532483
Provider Name (Legal Business Name): MR. MADUABUROCHUKWU J NWAJIAKU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N ROBINSON ST STE 200
RICHMOND VA
23220-4460
US

IV. Provider business mailing address

1700 FRONT ST
RICHMOND VA
23222-4098
US

V. Phone/Fax

Practice location:
  • Phone: 804-773-1571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number0024188927
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0024188927
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: