Healthcare Provider Details

I. General information

NPI: 1285041731
Provider Name (Legal Business Name): DR. IVAN NWAOGU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: N/A N/A N/A PHARMD

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 FALLBROOK WAY
LAS CRUCES NM
88011-4296
US

IV. Provider business mailing address

2528 FALLBROOK WAY
LAS CRUCES NM
88011-4296
US

V. Phone/Fax

Practice location:
  • Phone: 443-854-4727
  • Fax:
Mailing address:
  • Phone: 443-854-4727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number00007746
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number51338
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: