Provider Demographics
NPI:1437578440
Name:MBAGWU, EDITH (MD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:
Last Name:MBAGWU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:EDITH
Other - Middle Name:
Other - Last Name:IBENEME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3801 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3825
Mailing Address - Country:US
Mailing Address - Phone:225-387-7899
Mailing Address - Fax:225-381-2579
Practice Address - Street 1:3801 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3825
Practice Address - Country:US
Practice Address - Phone:225-381-6620
Practice Address - Fax:225-381-2579
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine