1104840032 NPI number — DR. KALU NDU BONIFACE AGWU MD

Table of content: DR. KALU NDU BONIFACE AGWU MD (NPI 1104840032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104840032 NPI number — DR. KALU NDU BONIFACE AGWU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGWU
Provider First Name:
KALU
Provider Middle Name:
NDU BONIFACE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AGWU
Provider Other First Name:
KALU
Provider Other Middle Name:
NDU BONIFACE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104840032
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37 WOODFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10970-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-744-0371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 LENOX AVE
Provider Second Line Business Practice Location Address:
HARLEM HOSPITAL
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10037-2206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-939-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0805X , with the licence number:  237607 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 237607 . This is a "NEW YORK STATE LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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