Provider Demographics
NPI:1699029793
Name:ODOCHI NWAGWU MD INC
Entity Type:Organization
Organization Name:ODOCHI NWAGWU MD INC
Other - Org Name:ADELANTO MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRICIAN/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ODOCHI
Authorized Official - Middle Name:N
Authorized Official - Last Name:NWAGWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-246-9555
Mailing Address - Street 1:11678 RANCHO RD
Mailing Address - Street 2:
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301-2700
Mailing Address - Country:US
Mailing Address - Phone:760-246-9555
Mailing Address - Fax:760-246-9115
Practice Address - Street 1:11678 RANCHO RD
Practice Address - Street 2:
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-2700
Practice Address - Country:US
Practice Address - Phone:760-246-9555
Practice Address - Fax:760-246-9115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG65429Medicare PIN