Healthcare Provider Details

I. General information

NPI: 1992740559
Provider Name (Legal Business Name): GODWIN IZUEGBUNAM MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8910 N 43RD AVE STE 104
GLENDALE AZ
85302-5340
US

IV. Provider business mailing address

1816 W PARNELL DR
PHOENIX AZ
85085-8020
US

V. Phone/Fax

Practice location:
  • Phone: 602-595-2986
  • Fax: 602-595-3041
Mailing address:
  • Phone: 602-595-2986
  • Fax: 602-595-3041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number31461
License Number StateAZ

VIII. Authorized Official

Name: EDITH C IZUEGBUNAM
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-595-2986