Provider Demographics
NPI:1427127075
Name:AJANWACHUKU, VINCENT EDE (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:EDE
Last Name:AJANWACHUKU
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 1:16133 KAMANA RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1377
Mailing Address - Country:US
Mailing Address - Phone:760-242-8491
Mailing Address - Fax:760-242-8495
Practice Address - Street 1:16133 KAMANA RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1377
Practice Address - Country:US
Practice Address - Phone:760-242-8491
Practice Address - Fax:760-242-8495
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA437360208600000X, 2086S0127X, 2086X0206X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A437360Medicare ID - Type Unspecified
CA00A29732Medicare UPIN