Provider Demographics
NPI:1881097442
Name:MBAGWU, CHUKWUDI YAGAZIE (MD)
Entity type:Individual
Prefix:
First Name:CHUKWUDI
Middle Name:YAGAZIE
Last Name:MBAGWU
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 1:33560 ALVARADO NILES RD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-3111
Mailing Address - Country:US
Mailing Address - Phone:510-489-8700
Mailing Address - Fax:510-489-8700
Practice Address - Street 1:33560 ALVARADO NILES RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-3111
Practice Address - Country:US
Practice Address - Phone:510-489-8700
Practice Address - Fax:510-489-2643
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301106425208D00000X
KYR41352083P0901X
CAA1607022083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice