Provider Demographics
NPI:1225010903
Name:NWAGWU, ODOCHI N (MD)
Entity Type:Individual
Prefix:DR
First Name:ODOCHI
Middle Name:N
Last Name:NWAGWU
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 1:11678 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 1:11678 RANCHO RD
Practice Address - Street 2:
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-2700
Practice Address - Country:US
Practice Address - Phone:760-246-9555
Practice Address - Fax:760-246-9115
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-06-20
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-07-26
Provider Licenses
StateLicense IDTaxonomies
CAG77049174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G770491Medicaid
CA4501031Medicaid
CA00G770490Medicare PIN
CAG65429Medicare UPIN