Provider Demographics
NPI:1356492805
Name:IGIETSU, AHMADU
Entity Type:Individual
Prefix:MR
First Name:AHMADU
Middle Name:
Last Name:IGIETSU
Suffix:
Gender:M
Credentials:
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 182158
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76096-2158
Mailing Address - Country:US
Mailing Address - Phone:817-300-3640
Mailing Address - Fax:817-277-4406
Practice Address - Street 1:1411 E. ABRAM ST STE D
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010
Practice Address - Country:US
Practice Address - Phone:817-300-3640
Practice Address - Fax:817-277-4406
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0093044332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6062980001Medicare NSC