Provider Demographics
NPI:1831236959
Name:K N SOLOMON MBAGWU MD INC. A PROFESSIONAL MEDICAL GROUP
Entity type:Organization
Organization Name:K N SOLOMON MBAGWU MD INC. A PROFESSIONAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:K.N.
Authorized Official - Middle Name:SOLOMON
Authorized Official - Last Name:MBAGWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-672-4881
Mailing Address - Street 1:10024 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3112
Mailing Address - Country:US
Mailing Address - Phone:323-242-0139
Mailing Address - Fax:323-242-0149
Practice Address - Street 1:10024 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3112
Practice Address - Country:US
Practice Address - Phone:323-242-0139
Practice Address - Fax:323-242-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42217207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G422170Medicaid
CA9445835Medicare UPIN