Healthcare Provider Details

I. General information

NPI: 1629423223
Provider Name (Legal Business Name): UGONNA E EZEH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 E LOHMAN AVE
LAS CRUCES NM
88011-8255
US

IV. Provider business mailing address

4351 E LOHMAN AVE
LAS CRUCES NM
88011-8259
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-9755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberR-03-2016MNT
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberDO2021-0038
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: