Healthcare Provider Details

I. General information

NPI: 1225010903
Provider Name (Legal Business Name): ODOCHI N NWAGWU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 07/26/2007

III. Provider practice location address

11678 RANCHO RD
ADELANTO CA
92301-2700
US

IV. Provider business mailing address

11678 RANCHO RD
ADELANTO CA
92301-2700
US

V. Phone/Fax

Practice location:
  • Phone: 760-246-9555
  • Fax: 760-246-9115
Mailing address:
  • Phone: 760-246-9555
  • Fax: 760-246-9115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG77049
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG77049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: