Healthcare Provider Details

I. General information

NPI: 1073900213
Provider Name (Legal Business Name): RAPHAEL UGWU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PICACHO ROAD
WINTERHAVEN CA
92283
US

IV. Provider business mailing address

PO BOX 1368
YUMA AZ
85366-1368
US

V. Phone/Fax

Practice location:
  • Phone: 760-572-4100
  • Fax: 760-572-2113
Mailing address:
  • Phone: 760-572-4100
  • Fax: 760-572-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number19127
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number13718I
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: