Provider Demographics
NPI:1558580795
Name:EZEOLU, POLYCARP I (PTA)
Entity Type:Individual
Prefix:MR
First Name:POLYCARP
Middle Name:I
Last Name:EZEOLU
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9832 57TH AVE
Mailing Address - Street 2:SUITE 12-G
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4914
Mailing Address - Country:US
Mailing Address - Phone:718-271-0526
Mailing Address - Fax:
Practice Address - Street 1:9832 57TH AVE
Practice Address - Street 2:SUITE 12-G
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-4914
Practice Address - Country:US
Practice Address - Phone:718-271-0526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003536251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health