Provider Demographics
NPI:1013211515
Name:IKEZI, GERALD O
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:O
Last Name:IKEZI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17330 113TH AVE
Mailing Address - Street 2:
Mailing Address - City:ADDISLEIGH PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11433-4003
Mailing Address - Country:US
Mailing Address - Phone:718-207-3292
Mailing Address - Fax:
Practice Address - Street 1:17330 113TH AVE
Practice Address - Street 2:
Practice Address - City:ADDISLEIGH PARK
Practice Address - State:NY
Practice Address - Zip Code:11433-4003
Practice Address - Country:US
Practice Address - Phone:718-207-3292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007775-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant