Provider Demographics
NPI:1508997925
Name:NWAGBATA, EBELECHUKWU (MD)
Entity Type:Individual
Prefix:DR
First Name:EBELECHUKWU
Middle Name:
Last Name:NWAGBATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EBELECHUKWU
Other - Middle Name:
Other - Last Name:EKUNNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 WALLER ST
Mailing Address - Street 2:5TH FLOOR, ATT: FINANCE
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-5240
Mailing Address - Country:US
Mailing Address - Phone:512-978-9000
Mailing Address - Fax:
Practice Address - Street 1:6801 S IH 35
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-4824
Practice Address - Country:US
Practice Address - Phone:512-978-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-117140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL170421Medicare UPIN