Basic Information
| Provider Information | |||||||||
| NPI: | 1962440875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGBONIM | ||||||||
| FirstName: | DONATUS | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6210 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874996210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092258 | ||||||||
| FaxNumber: | 5056092259 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 W MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874015630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N3018 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 20233 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | N3018 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD2018-0202 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0116367 | 01 | SC | GHI | OTHER | 202337 | 05 | SC | MEDICAID | P00423235 | 01 | SC | RAILROAD MEDICARE | OTHER | 20049632 | 01 | SC | SELECT HEALTH FIRST CHOICE | OTHER |