Provider Demographics
NPI:1497499719
Name:EHIMAMIEGHO, PRINCE OSAZUWA (MD)
Entity Type:Individual
Prefix:
First Name:PRINCE
Middle Name:OSAZUWA
Last Name:EHIMAMIEGHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9466 MOURVERDE CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-4611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1080
Practice Address - Country:US
Practice Address - Phone:309-672-4977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000000000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program