Basic Information
| Provider Information | |||||||||
| NPI: | 1730524406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMELIA C WOGU MD LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3380 LA SIERRA AVE STE 104-613 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925035271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513675586 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | KING CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939303431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2013 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCTS MGR | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 19686 | MT | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | A102408 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 19686 | 01 | MT | MT LIC | OTHER | A102408 | 01 | CA | CA LIC | OTHER |