Provider Demographics
NPI:1912000134
Name:AHAGHOTU, CHILEDUM A (MD)
Entity Type:Individual
Prefix:
First Name:CHILEDUM
Middle Name:A
Last Name:AHAGHOTU
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 1:2024 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-3027
Mailing Address - Country:US
Mailing Address - Phone:202-595-3223
Mailing Address - Fax:202-332-2985
Practice Address - Street 1:2139 GEORGIA AVE NW
Practice Address - Street 2:SUITE 3D
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-0001
Practice Address - Country:US
Practice Address - Phone:202-865-7022
Practice Address - Fax:202-865-7027
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD31149208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7504608Medicaid
011610H13Medicare PIN
VA7504608Medicaid