Healthcare Provider Details

I. General information

NPI: 1285769364
Provider Name (Legal Business Name): CHIDOZIE C MBAGWU M.D., PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 MAGNOLIA AVE STE I
RIVERSIDE CA
92505-1819
US

IV. Provider business mailing address

10600 MAGNOLIA AVE SUITE I
RIVERSIDE CA
92505-1819
US

V. Phone/Fax

Practice location:
  • Phone: 951-324-8100
  • Fax: 951-324-8103
Mailing address:
  • Phone: 951-324-8100
  • Fax: 951-324-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA51399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: