Provider Demographics
NPI:1871758649
Name:EZUGHA, HERBERT OSITA (MD)
Entity type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:OSITA
Last Name:EZUGHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HERBERT
Other - Middle Name:OSITA
Other - Last Name:EZUGHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:2500 WIGWAM PKWY STE 111
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7113
Mailing Address - Country:US
Mailing Address - Phone:702-852-1155
Mailing Address - Fax:702-246-0195
Practice Address - Street 1:2500 WIGWAM PKWY STE 111
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7113
Practice Address - Country:US
Practice Address - Phone:702-852-1155
Practice Address - Fax:702-246-0195
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1275632084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMT 191786OtherMT191786