Provider Demographics
NPI:1962446252
Name:UWENSUYI-EDOSOMWAN, FIDELIS IGUODALA (MD)
Entity Type:Individual
Prefix:DR
First Name:FIDELIS
Middle Name:IGUODALA
Last Name:UWENSUYI-EDOSOMWAN
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 1:1805 MILTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-2437
Mailing Address - Country:US
Mailing Address - Phone:704-535-0400
Mailing Address - Fax:704-535-3443
Practice Address - Street 1:1805 MILTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-2437
Practice Address - Country:US
Practice Address - Phone:704-535-0400
Practice Address - Fax:704-535-3443
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012WUMedicaid
NC89012WUMedicaid