Provider Demographics
NPI:1477547826
Name:NWAEZE, IJEOMA O (MD)
Entity Type:Individual
Prefix:
First Name:IJEOMA
Middle Name:O
Last Name:NWAEZE
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 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:10701 VINTAGE PRESERVE PKWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-2158
Practice Address - Country:US
Practice Address - Phone:713-442-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4898207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX356834703Medicaid
TX356834702Medicaid
TX356834703Medicaid
WIP00772304OtherRR MEDICARE
TX356834703Medicaid
TX373402YKTXMedicare PIN
WIP00772304OtherRR MEDICARE
WI46236-0331Medicare PIN
TX373402YKTVMedicare PIN
TX373402YKTUMedicare PIN