Provider Demographics
NPI:1063938603
Name:ODIMEGWU, ANTHONY I
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:I
Last Name:ODIMEGWU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26062 BERCAW CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-1702
Mailing Address - Country:US
Mailing Address - Phone:909-255-5786
Mailing Address - Fax:
Practice Address - Street 1:26062 BERCAW CT
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555
Practice Address - Country:US
Practice Address - Phone:909-255-5786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006412363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily