Provider Demographics
NPI:1669568796
Name:NDUAGUBA-EZUMBA, ANGELA (DO)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:NDUAGUBA-EZUMBA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 BEDFORD AVENUE, SUITE 113
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208
Mailing Address - Country:US
Mailing Address - Phone:443-883-0229
Mailing Address - Fax:410-484-5522
Practice Address - Street 1:1314 BEDFORD AVENUE, SUITE 113
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208
Practice Address - Country:US
Practice Address - Phone:443-883-0229
Practice Address - Fax:410-484-5522
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD800662552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14071Medicaid
MN12N73NDOtherBCBS MN
ND26621OtherBLUE CROSS BLUE SHIELD ND
MN438655000Medicaid