Provider Demographics
NPI:1871721696
Name:IKEZUAGU, MBONU NNAJI (MD)
Entity type:Individual
Prefix:
First Name:MBONU
Middle Name:NNAJI
Last Name:IKEZUAGU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-702-6371
Mailing Address - Fax:920-993-5037
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-702-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-099233207R00000X
WI81640208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067250Medicaid
OH35-099233OtherOHIO MEDICAL LICENSE
OHH102600Medicare PIN