Provider Demographics
NPI:1689068074
Name:EGO-OSUALA, IKENNA
Entity Type:Individual
Prefix:DR
First Name:IKENNA
Middle Name:
Last Name:EGO-OSUALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12601 PLEASANT PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2522
Mailing Address - Country:US
Mailing Address - Phone:240-603-3447
Mailing Address - Fax:
Practice Address - Street 1:760 RADCLIFFE AVE
Practice Address - Street 2:00013
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:302-555-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program