Provider Demographics
NPI:1578095865
Name:EZIDIEGWU, LINDA UGOCHINYERE
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:UGOCHINYERE
Last Name:EZIDIEGWU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST BLDG 8280
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 S 11TH ST BLDG 8280
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-7196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD473710207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program