Basic Information
| Provider Information | |||||||||
| NPI: | 1871721696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IKEZUAGU | ||||||||
| FirstName: | MBONU | ||||||||
| MiddleName: | NNAJI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 FRANKLIN AVE | ||||||||
| Address2: | MERCY INTERNAL MEDICINE PHYSICIANS FAMILY CARE CENTER | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436201402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192512360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2213 FRANKLIN AVE | ||||||||
| Address2: | MERCY INTERNAL MEDICINE PHYSICIANS FAMILY CARE CENTER | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436201402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192512360 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 02/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-099233 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 35-099233 | 01 | OH | OHIO MEDICAL LICENSE | OTHER | 0067250 | 05 | OH | MEDICAID |