Provider Demographics
NPI:1306839659
Name:EZEIGBO, WALTER AZUBUIKE (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:AZUBUIKE
Last Name:EZEIGBO
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 1:1000 SOUTHPARK BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-5072
Mailing Address - Country:US
Mailing Address - Phone:336-788-4545
Mailing Address - Fax:336-788-4556
Practice Address - Street 1:1000 SOUTHPARK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-5072
Practice Address - Country:US
Practice Address - Phone:336-788-4545
Practice Address - Fax:336-788-4556
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891075WMedicaid
NC891075WMedicaid
2243964BMedicare ID - Type Unspecified