Provider Demographics
NPI:1518945674
Name:EZENWABACHILI, OBIAJULU CLETUS (MD)
Entity Type:Individual
Prefix:DR
First Name:OBIAJULU
Middle Name:CLETUS
Last Name:EZENWABACHILI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7737 SOUTHWEST FWY
Mailing Address - Street 2:STE 620
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-1807
Mailing Address - Country:US
Mailing Address - Phone:713-484-9100
Mailing Address - Fax:713-484-7558
Practice Address - Street 1:7737 SOUTHWEST FWY
Practice Address - Street 2:STE 620
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1807
Practice Address - Country:US
Practice Address - Phone:713-484-9100
Practice Address - Fax:713-484-7558
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL0158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0089GLOtherBLUECROSS BLUE SHIELD TX
H08581Medicare UPIN
00908WMedicare ID - Type Unspecified