Provider Demographics
NPI:1598743254
Name:EZEANOLUE, ECHEZONA EDOZIE (MD)
Entity Type:Individual
Prefix:
First Name:ECHEZONA
Middle Name:EDOZIE
Last Name:EZEANOLUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 W CHARLESTON BLVD
Mailing Address - Street 2:#215
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2325
Mailing Address - Country:US
Mailing Address - Phone:702-671-2355
Mailing Address - Fax:702-382-5388
Practice Address - Street 1:3006 S MARYLAND PKWY
Practice Address - Street 2:315
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2218
Practice Address - Country:US
Practice Address - Phone:702-992-6868
Practice Address - Fax:702-992-6860
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV110272080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506925Medicaid
NVCS13694OtherSTATE PHARMACY
NVCS13694OtherSTATE PHARMACY
NV100506925Medicaid
NVCE075ZMedicare PIN
NV101386Medicare ID - Type UnspecifiedMEDICARE