Provider Demographics
NPI:1699844886
Name:IWUAGWU, ANTHONY O (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:O
Last Name:IWUAGWU
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 1:2200 GRANT ST
Mailing Address - Street 2:STE 207
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46404-3439
Mailing Address - Country:US
Mailing Address - Phone:219-944-7565
Mailing Address - Fax:219-944-1304
Practice Address - Street 1:2200 GRANT ST
Practice Address - Street 2:STE 207
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46404-3439
Practice Address - Country:US
Practice Address - Phone:219-944-7565
Practice Address - Fax:219-944-1304
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051456A207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200247520AMedicaid
IN145710Medicare ID - Type Unspecified
IN200247520AMedicaid