Provider Demographics
NPI:1619934320
Name:ODUMODU, NWANNEKA U (MD)
Entity type:Individual
Prefix:
First Name:NWANNEKA
Middle Name:U
Last Name:ODUMODU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16184 E 10 MILE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1160
Mailing Address - Country:US
Mailing Address - Phone:586-779-4550
Mailing Address - Fax:
Practice Address - Street 1:16184 E 10 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021
Practice Address - Country:US
Practice Address - Phone:586-779-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080H262390OtherBLUE CROSS-BLUE CROSS
MI478692310Medicaid
NO077637OtherCHAMPUS-CHAMPUS
NO077637OtherCOMMERCIAL-COMMERCIAL NUMBER
MI478692310Medicaid
080H262390OtherBLUE CROSS-BLUE CROSS