Healthcare Provider Details

I. General information

NPI: 1407368541
Provider Name (Legal Business Name): FAITH EZENOGHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNM HOSPITAL 2211 LOMAS BLVD, SE
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 504-496-8064
  • Fax: 504-496-8064
Mailing address:
  • Phone: 505-272-6331
  • Fax: 505-272-0475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number16000047
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2017-1062
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: