Provider Demographics
NPI:1871097980
Name:UKONNE, INIOBONG
Entity type:Individual
Prefix:
First Name:INIOBONG
Middle Name:
Last Name:UKONNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 BLOOMFIELD AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1374
Mailing Address - Country:US
Mailing Address - Phone:973-746-7050
Mailing Address - Fax:
Practice Address - Street 1:1 BAY AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4837
Practice Address - Country:US
Practice Address - Phone:973-330-1269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10901400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program