Healthcare Provider Details

I. General information

NPI: 1063702553
Provider Name (Legal Business Name): CRYSTAL UGOCHI AGUH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: UGOCHI CRYSTAL AGI M.D.

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 ORLEANS ST CRB II ROOM 211
BALTIMORE MD
21287-0014
US

IV. Provider business mailing address

1550 ORLEANS ST CRB II ROOM 211
BALTIMORE MD
21287-0014
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-2400
  • Fax: 410-955-8645
Mailing address:
  • Phone: 410-955-2400
  • Fax: 410-955-8645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD80005
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: