Basic Information
| Provider Information | |||||||||
| NPI: | 1508199530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NWANNUNU | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | NWANNUNU | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3926 NEW VISION DR | ||||||||
| Address2: | CONNERSVILLE | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
| FaxNumber: | 2604585636 | ||||||||
| Practice Location | |||||||||
| Address1: | 1889 E STATE ROAD 44 | ||||||||
| Address2: | CONNERSVILLE | ||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473318232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8322137392 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01032665A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.