MEDICARE: OBINNA I MADUKA MD

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	208000000X	Pediatrics Physician	037518	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710065917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OBINNA I MADUKA MD

Provider Business Mailing Address
First Line	:	387 TUCKIE RD STE C
Second Line	:
City	:	NORTH WINDHAM
State	:	CT
Zip	:	06256-1355
Country	:	US
Telephone Number	:	860-456-1279
Fax Number	:	860-456-1298

Provider Business Practice Location Address
First Line	:	387 TUCKIE RD STE C
Second Line	:
City	:	NORTH WINDHAM
State	:	CT
Zip	:	06256-1355
Country	:	US
Telephone Number	:	860-456-1279
Fax Number	:	860-456-1298

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

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	07/08/2007

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