=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659424398
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NNAMDI MADUEKWE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 07/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 81 HALLEY DRIVE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-286-9770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81 HALLEY DRIVE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-286-9770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 244833
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 72661
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 244833
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------