Provider Demographics
NPI:1679576565
Name:AGUNANNE, ENOCH ECHEZONA (MD)
Entity type:Individual
Prefix:DR
First Name:ENOCH
Middle Name:ECHEZONA
Last Name:AGUNANNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:311 W COUNTRY CLUB RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5839
Mailing Address - Country:US
Mailing Address - Phone:575-625-3400
Mailing Address - Fax:575-625-3415
Practice Address - Street 1:311 W COUNTRY CLUB RD STE 1
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5839
Practice Address - Country:US
Practice Address - Phone:575-625-3400
Practice Address - Fax:575-625-3415
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6755207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161539502Medicaid
TX161539501Medicaid