Healthcare Provider Details

I. General information

NPI: 1730524406
Provider Name (Legal Business Name): CAMELIA C WOGU MD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CANAL ST
KING CITY CA
93930-3431
US

IV. Provider business mailing address

3380 LA SIERRA AVE STE 104-613
RIVERSIDE CA
92503-5271
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 951-367-5586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number19686
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA102408
License Number StateCA

VIII. Authorized Official

Name: LORI LABRECQUE
Title or Position: ACCTS MGR
Credential:
Phone: 702-453-3799