Provider Demographics
NPI:1396842787
Name:EZENEKWE, AMOBI (MD)
Entity Type:Individual
Prefix:
First Name:AMOBI
Middle Name:
Last Name:EZENEKWE
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 1:103 CONTINENTAL PL STE 400
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-1073
Mailing Address - Country:US
Mailing Address - Phone:615-916-3217
Mailing Address - Fax:615-916-3218
Practice Address - Street 1:6116 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-5703
Practice Address - Country:US
Practice Address - Phone:303-512-0888
Practice Address - Fax:303-512-2268
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060496207ZP0102X
CODR.0059994207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INI36833Medicare UPIN
IN738980ZMedicare ID - Type Unspecified