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General NPI Number Information
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NPI Number | 1689201832
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Entity Type | Individual
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Provider Name | IFEANYI JEFFREY MBAH MD
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Gender | Male
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Dates
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Enumeration Date | 03/26/2020
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Last Update Date | 10/07/2025
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Provider Practice Location Address
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Address Line | 820 ARBUTUS AVE STE 102
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City | OCONTO
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State | WI
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Zip | 54153-2004
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Country | US
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Telephone | 920-834-8833
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Fax |
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Provider Business Mailing Address
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Address Line | 2851 UNIVERSITY AVE
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City | GREEN BAY
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State | WI
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Zip | 54311-5855
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Country | US
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Telephone | 920-431-2642
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 76210-20
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License Number State | WI
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