Provider Demographics
NPI:1548486947
Name:NWAIGWE, MANASSEH C (MD)
Entity type:Individual
Prefix:
First Name:MANASSEH
Middle Name:C
Last Name:NWAIGWE
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:P.O. BOX 479
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754
Mailing Address - Country:US
Mailing Address - Phone:323-881-6465
Mailing Address - Fax:323-261-8768
Practice Address - Street 1:1159 S. LORENA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023
Practice Address - Country:US
Practice Address - Phone:323-881-6465
Practice Address - Fax:323-261-8768
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42352208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A425320Medicaid
CAAV904YOtherPTAN
CAAV904ZOtherMEDICARE PTAN
CA00A425320Medicaid
CAE64336Medicare UPIN