Provider Demographics
NPI:1194720110
Name:EZEUGWU, CAMELLUS O (MD)
Entity type:Individual
Prefix:
First Name:CAMELLUS
Middle Name:O
Last Name:EZEUGWU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 SAINT JOHNS LN
Mailing Address - Street 2:PO BOX 6545
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-5337
Mailing Address - Country:US
Mailing Address - Phone:410-225-8615
Mailing Address - Fax:410-462-5095
Practice Address - Street 1:300 ARMORY PL
Practice Address - Street 2:STE 3M
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4603
Practice Address - Country:US
Practice Address - Phone:410-225-8615
Practice Address - Fax:410-462-5095
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053981174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF85959Medicare UPIN
MD736MMedicare ID - Type Unspecified