Provider Demographics
NPI:1689216954
Name:EZEDIKE, VINCENT UZEGBULEM
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:UZEGBULEM
Last Name:EZEDIKE
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 1:300 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4260
Mailing Address - Country:US
Mailing Address - Phone:410-545-8146
Mailing Address - Fax:
Practice Address - Street 1:300 E MADISON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4260
Practice Address - Country:US
Practice Address - Phone:410-545-8146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR158310363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health