Provider Demographics
NPI:1871138776
Name:CHIDOMERE, IKECHUKWU C
Entity type:Individual
Prefix:MR
First Name:IKECHUKWU
Middle Name:C
Last Name:CHIDOMERE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16731 BEECHNUT ST APT 206
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-6642
Mailing Address - Country:US
Mailing Address - Phone:281-902-8410
Mailing Address - Fax:
Practice Address - Street 1:16731 BEECHNUT ST APT 206
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-6642
Practice Address - Country:US
Practice Address - Phone:281-902-8410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU92586271Medicaid