Basic Information
| Provider Information | |||||||||
| NPI: | 1912000134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AHAGHOTU | ||||||||
| FirstName: | CHILEDUM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2024 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200013027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025953223 | ||||||||
| FaxNumber: | 2023322985 | ||||||||
| Practice Location | |||||||||
| Address1: | 2139 GEORGIA AVE NW | ||||||||
| Address2: | SUITE 3D | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028657022 | ||||||||
| FaxNumber: | 2028657027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 08/03/2007 | ||||||||
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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 | 208800000X | MD31149 | DC | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 7504608 | 05 | VA | MEDICAID |