Provider Demographics
NPI:1073900213
Name:UGWU, RAPHAEL
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:UGWU
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:PO BOX 1368
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-1368
Mailing Address - Country:US
Mailing Address - Phone:760-572-4100
Mailing Address - Fax:760-572-2113
Practice Address - Street 1:401 PICACHO ROAD
Practice Address - Street 2:
Practice Address - City:WINTERHAVEN
Practice Address - State:CA
Practice Address - Zip Code:92283
Practice Address - Country:US
Practice Address - Phone:760-572-4100
Practice Address - Fax:760-572-2113
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19127208D00000X
PR13718I208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice