Provider Demographics
NPI:1962009712
Name:ITEDJERE, AVWEROSUOGHENE JUDE
Entity Type:Individual
Prefix:DR
First Name:AVWEROSUOGHENE
Middle Name:JUDE
Last Name:ITEDJERE
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 1:619 E 187TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-6706
Mailing Address - Country:US
Mailing Address - Phone:718-365-8630
Mailing Address - Fax:
Practice Address - Street 1:619 E 187TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6706
Practice Address - Country:US
Practice Address - Phone:718-365-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist