Provider Demographics
NPI:1841856499
Name:EGO-OSUALA, KELECHI
Entity type:Individual
Prefix:
First Name:KELECHI
Middle Name:
Last Name:EGO-OSUALA
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 1:5305 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-3101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5305 KENILWORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-3101
Practice Address - Country:US
Practice Address - Phone:301-277-7110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-18
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0095010207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine