Basic Information
| Provider Information | |||||||||
| NPI: | 1730509639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBEKWE | ||||||||
| FirstName: | USONWANNE | ||||||||
| MiddleName: | UCHENNA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NWOSU | ||||||||
| OtherFirstName: | USONWANNE | ||||||||
| OtherMiddleName: | UCHENNA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2323 N LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142704932 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 788 N JEFFERSON ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532023710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142728950 | ||||||||
| FaxNumber: | 4142720859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2014 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 67409 | WI | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RE0101X | 67409 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 1730509639 | 05 | WI | MEDICAID |