Provider Demographics
NPI:1518921188
Name:IGWEMEZIE, BENJAMIN MADUAKONAM (MD)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:MADUAKONAM
Last Name:IGWEMEZIE
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 1:635 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27260-5017
Mailing Address - Country:US
Mailing Address - Phone:336-887-0038
Mailing Address - Fax:336-885-8096
Practice Address - Street 1:635 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27260-5017
Practice Address - Country:US
Practice Address - Phone:336-887-0038
Practice Address - Fax:336-885-8096
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94-01418174400000X
NC9401418207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8945208Medicaid
NC8945208Medicaid
NC2207498CMedicare ID - Type Unspecified