Provider Demographics
NPI:1114130069
Name:MADUKA-EZEH, AWELE N (MD)
Entity Type:Individual
Prefix:DR
First Name:AWELE
Middle Name:N
Last Name:MADUKA-EZEH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HYGEIA DR
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:302-623-7362
Mailing Address - Fax:
Practice Address - Street 1:200 HYGEIA DR
Practice Address - Street 2:SUITE 2300
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2049
Practice Address - Country:US
Practice Address - Phone:302-623-7362
Practice Address - Fax:302-623-0117
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188393207R00000X
MN104333207RI0200X
MN52291207RI0200X
DEC1-0009931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN440000282Medicare PIN