MEDICARE: DR. NNEKA UDONNA ICHOKU D.O., MPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0030507	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2016016734	OTHER	MO	MO LICENSE

General Provider Information

NPI Number	:	1548422215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NNEKA UDONNA ICHOKU D.O., MPH

Provider Business Mailing Address
First Line	:	1551 WALL ST
Second Line	:	SUITE 310
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3539
Country	:	US
Telephone Number	:	636-669-2268
Fax Number	:

Provider Business Practice Location Address
First Line	:	9759 MANCHESTER RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-1346
Country	:	US
Telephone Number	:	314-781-4922
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2008
Last Update Date	:	07/28/2016

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