Provider Demographics
NPI:1497242879
Name:IKWUEZUNMA, PAUL OKECHUKWU
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:OKECHUKWU
Last Name:IKWUEZUNMA
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 1:951 STAFFORDALE MANOR LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77047-4592
Mailing Address - Country:US
Mailing Address - Phone:832-614-2979
Mailing Address - Fax:
Practice Address - Street 1:951 STAFFORDALE MANOR LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77047-4592
Practice Address - Country:US
Practice Address - Phone:832-614-2979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX344600000X172A00000X
TX343900000X172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver