Healthcare Provider Details

I. General information

NPI: 1336408293
Provider Name (Legal Business Name): IFEANYI MBADUGHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 N SAINT MARYS ST
BEEVILLE TX
78102-3420
US

IV. Provider business mailing address

1003 N SAINT MARYS ST
BEEVILLE TX
78102-3420
US

V. Phone/Fax

Practice location:
  • Phone: 361-492-5252
  • Fax: 361-492-5599
Mailing address:
  • Phone: 361-492-5252
  • Fax: 361-492-5599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP2492
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: