Provider Demographics
NPI:1710175823
Name:NZEREM, IFEYINWA R
Entity Type:Individual
Prefix:
First Name:IFEYINWA
Middle Name:R
Last Name:NZEREM
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 1:714 W 53RD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-1514
Mailing Address - Country:US
Mailing Address - Phone:765-683-0633
Mailing Address - Fax:765-683-0603
Practice Address - Street 1:714 W 53RD ST
Practice Address - Street 2:SUITE A
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-1514
Practice Address - Country:US
Practice Address - Phone:765-683-0633
Practice Address - Fax:765-683-0603
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004264A171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN156635Medicare PIN