Provider Demographics
NPI:1407175631
Name:EZEALA, EUGENE MBADIWE
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:MBADIWE
Last Name:EZEALA
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 1:1713 VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3860
Mailing Address - Country:US
Mailing Address - Phone:310-619-8514
Mailing Address - Fax:
Practice Address - Street 1:1713 VICTORIA DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3860
Practice Address - Country:US
Practice Address - Phone:310-619-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health