Provider Demographics
NPI:1174827125
Name:ODOCHI NWAGWU MD INC
Entity Type:Organization
Organization Name:ODOCHI NWAGWU MD INC
Other - Org Name:SPECTRUM URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ODOCHI
Authorized Official - Middle Name:N
Authorized Official - Last Name:NWAGWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-403-5571
Mailing Address - Street 1:11678 RANCHO RD
Mailing Address - Street 2:
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301-2700
Mailing Address - Country:US
Mailing Address - Phone:760-246-9555
Mailing Address - Fax:760-246-9115
Practice Address - Street 1:15095 AMARGOSA RD
Practice Address - Street 2:SUITE 280
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1879
Practice Address - Country:US
Practice Address - Phone:760-952-9100
Practice Address - Fax:760-952-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84056207R00000X
261QU0200X
CAPA18372363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225010903OtherNPPES
CA00G770491Medicaid
CA00G770491Medicaid
CA4501031Medicare PIN