Provider Demographics
NPI:1285041731
Name:NWAOGU, IVAN
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:NWAOGU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:2528 FALLBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4296
Mailing Address - Country:US
Mailing Address - Phone:443-854-4727
Mailing Address - Fax:
Practice Address - Street 1:2528 FALLBROOK WAY
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4296
Practice Address - Country:US
Practice Address - Phone:443-854-4727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM00007746183500000X
TX51338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist