Basic Information
| Provider Information | |||||||||
| NPI: | 1972598530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IWUAGWU | ||||||||
| FirstName: | CLETUS | ||||||||
| MiddleName: | U | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835614 | ||||||||
| FaxNumber: | 4193835618 | ||||||||
| Practice Location | |||||||||
| Address1: | 3355 GLENDALE AVE | ||||||||
| Address2: | MEDICINE | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835614 | ||||||||
| FaxNumber: | 4193835618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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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 | 207RG0300X | 35075720 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2128218 | 05 | OH | MEDICAID |