MEDICARE: DR. TAGBO JOHN EKWONU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9900826	NC
2	261Q00000X	Clinic/Center	9900826	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1235R	OTHER	NC	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093890535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAGBO JOHN EKWONU M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1280
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28106-1280
Country	:	US
Telephone Number	:	704-532-4567
Fax Number	:	704-532-4580

Provider Business Practice Location Address
First Line	:	4115 THE PLZ
Second Line	:	EASTOWNE FAMILY PHYSICIANS, P.A,
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1356
Country	:	US
Telephone Number	:	704-532-4567
Fax Number	:	704-532-4580

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	03/30/2022

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