Healthcare Provider Details

I. General information

NPI: 1992093678
Provider Name (Legal Business Name): IHEANYICHUKWU OGU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1249 15TH ST
HUNTINGTON WV
25701-3662
US

IV. Provider business mailing address

1150 N 18TH ST STE 300
ABILENE TX
79601-2931
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1000
  • Fax:
Mailing address:
  • Phone: 325-670-2255
  • Fax: 325-670-5537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number26890
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberT3842
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: