Provider Demographics
NPI:1093846453
Name:IWUAGWU, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:IWUAGWU
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 1:5021 W AVENUE M
Mailing Address - Street 2:
Mailing Address - City:QUARTZ HILL
Mailing Address - State:CA
Mailing Address - Zip Code:93536-3010
Mailing Address - Country:US
Mailing Address - Phone:661-718-3870
Mailing Address - Fax:661-718-3970
Practice Address - Street 1:5021 W AVENUE M
Practice Address - Street 2:
Practice Address - City:QUARTZ HILL
Practice Address - State:CA
Practice Address - Zip Code:93536-3010
Practice Address - Country:US
Practice Address - Phone:661-718-3870
Practice Address - Fax:661-718-3970
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA47180332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47180OtherHMDR
CA47180OtherHMDR