Provider Demographics
NPI:1992740559
Name:GODWIN IZUEGBUNAM MD PC
Entity type:Organization
Organization Name:GODWIN IZUEGBUNAM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:C
Authorized Official - Last Name:IZUEGBUNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-595-2986
Mailing Address - Street 1:1816 W PARNELL DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8020
Mailing Address - Country:US
Mailing Address - Phone:602-595-2986
Mailing Address - Fax:602-595-3041
Practice Address - Street 1:8910 N 43RD AVE STE 104
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-5340
Practice Address - Country:US
Practice Address - Phone:602-595-2986
Practice Address - Fax:602-595-3041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31461207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ793837Medicaid
AZ793837Medicaid
AZZ101533Medicare PIN