Provider Demographics
NPI:1992058705
Name:NORTHSTAR INTERNAL MEDICINE PA
Entity type:Organization
Organization Name:NORTHSTAR INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:IKECHUKWU
Authorized Official - Middle Name:A
Authorized Official - Last Name:NWABUDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-209-9110
Mailing Address - Street 1:5720 APPALOSSA DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2522
Mailing Address - Country:US
Mailing Address - Phone:469-209-9110
Mailing Address - Fax:
Practice Address - Street 1:5720 APPALOSSA DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2522
Practice Address - Country:US
Practice Address - Phone:817-717-1299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN5288OtherTEXAS LICENSE