Provider Demographics
NPI:1053340869
Name:OKONKWO, NDUBUEZE FIDELIS (MD)
Entity type:Individual
Prefix:
First Name:NDUBUEZE
Middle Name:FIDELIS
Last Name:OKONKWO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2112
Mailing Address - Country:US
Mailing Address - Phone:316-321-3300
Mailing Address - Fax:316-321-2916
Practice Address - Street 1:720 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2112
Practice Address - Country:US
Practice Address - Phone:316-321-3300
Practice Address - Fax:316-321-2916
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2016-10-19
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-06-16
Provider Licenses
StateLicense IDTaxonomies
KS04-39127207R00000X
LALA09878R207RN0300X
LA09878R207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSPENDINGMedicaid
F46086Medicare UPIN
KSPENDINGMedicare PIN
F46086Medicare UPIN