Provider Demographics
NPI:1679578835
Name:EGO-OSUALA, GEORGE C (MD, FACP)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:C
Last Name:EGO-OSUALA
Suffix:
Gender:M
Credentials:MD, FACP
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 7909
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20787-7909
Mailing Address - Country:US
Mailing Address - Phone:301-434-9147
Mailing Address - Fax:301-434-9178
Practice Address - Street 1:7676 NEW HAMPSHIRE AVE
Practice Address - Street 2:STE 420
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-7516
Practice Address - Country:US
Practice Address - Phone:301-434-9147
Practice Address - Fax:301-434-9178
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD 47156207R00000X, 208D00000X
DCMD 21355207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0490330Medicaid
MD852000300Medicaid
MD852000300Medicaid
DC0490330Medicaid