Provider Demographics
NPI:1982864344
Name:NWANGUMA, ONYEOZIRI RAPHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ONYEOZIRI
Middle Name:RAPHAEL
Last Name:NWANGUMA
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 1:825 SECOND AVENUE EAST
Mailing Address - Street 2:SUITE A4
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1789
Mailing Address - Country:US
Mailing Address - Phone:270-796-6333
Mailing Address - Fax:270-780-2793
Practice Address - Street 1:825 SECOND AVENUE EAST
Practice Address - Street 2:SUITE A4
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1789
Practice Address - Country:US
Practice Address - Phone:717-531-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT049539T208600000X
KY45330208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100221340Medicaid
KY7100221340Medicaid