Provider Demographics
NPI:1073742953
Name:IBIE, NOWOGHOMWENMA CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:NOWOGHOMWENMA
Middle Name:CHARLES
Last Name:IBIE
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 1:207 HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2919
Mailing Address - Country:US
Mailing Address - Phone:334-793-3319
Mailing Address - Fax:334-793-2291
Practice Address - Street 1:207 HAVEN DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2919
Practice Address - Country:US
Practice Address - Phone:334-793-3319
Practice Address - Fax:334-793-2291
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30540207R00000X
ALMD.30540207P00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-12500OtherBCBS
AL125314Medicaid
AL1073742953OtherTRICARE SOUTH
ALZ14079OtherVIVA HEALTH
AL1073742953OtherTRICARE SOUTH