Healthcare Provider Details

I. General information

NPI: 1386328060
Provider Name (Legal Business Name): CHUKWUDI AMARACHUKWU NWOGU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 01/31/2024
Certification Date: 06/13/2023
Deactivation Date: 01/17/2024
Reactivation Date: 01/31/2024

III. Provider practice location address

3 RIVERSIDE CIRCLE, 2ND FLOOR NEUROLOGY DEPARTMENT
ROANOKE VA
24016
US

IV. Provider business mailing address

3330 CIRCLE BROOK DRIVE, APARTMENT F, ROANOKE
ROANOKE VA
24018
US

V. Phone/Fax

Practice location:
  • Phone: 540-224-5170
  • Fax: 540-985-9612
Mailing address:
  • Phone: 540-597-3357
  • Fax: 540-985-9612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0116038505
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: