Provider Demographics
NPI:1285769364
Name:MBAGWU, CHIDOZIE C (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:CHIDOZIE
Middle Name:C
Last Name:MBAGWU
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 MAGNOLIA AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1819
Mailing Address - Country:US
Mailing Address - Phone:951-324-8100
Mailing Address - Fax:951-324-8103
Practice Address - Street 1:10600 MAGNOLIA AVE
Practice Address - Street 2:STE I
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1819
Practice Address - Country:US
Practice Address - Phone:951-324-8100
Practice Address - Fax:951-324-8103
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51399174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A513990Medicaid
CA00A513991Medicare PIN
CA00A513990Medicaid