Basic Information
| Provider Information | |||||||||
| NPI: | 1356602429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUKWUMA | ||||||||
| FirstName: | IFEANYICHUKWU | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 FIRST COLONIAL RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573952323 | ||||||||
| FaxNumber: | 7573956280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 FIRST COLONIAL RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573952323 | ||||||||
| FaxNumber: | 7573956280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2012 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R-9360 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 0101258135 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 0101258135 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1356602429 | 05 | VA | MEDICAID |