Provider Demographics
NPI:1093890535
Name:EKWONU, TAGBO JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:TAGBO
Middle Name:JOHN
Last Name:EKWONU
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:PO BOX 1280
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28106-1280
Mailing Address - Country:US
Mailing Address - Phone:704-532-4567
Mailing Address - Fax:704-532-4580
Practice Address - Street 1:4115 THE PLZ
Practice Address - Street 2:EASTOWNE FAMILY PHYSICIANS, P.A,
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-1356
Practice Address - Country:US
Practice Address - Phone:704-532-4567
Practice Address - Fax:704-532-4580
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900826207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235ROtherBCBS
NC891235RMedicaid
NC891235RMedicaid
NC1235ROtherBCBS