Provider Demographics
NPI:1285442178
Name:MGBUDEM, DECLAN C
Entity type:Individual
Prefix:
First Name:DECLAN
Middle Name:C
Last Name:MGBUDEM
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 1:10449 TOWNLEY CT
Mailing Address - Street 2:
Mailing Address - City:REMINDERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44202-8152
Mailing Address - Country:US
Mailing Address - Phone:234-389-2121
Mailing Address - Fax:
Practice Address - Street 1:17403 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-1715
Practice Address - Country:US
Practice Address - Phone:234-389-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSS802996343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)