Provider Demographics
NPI:1720212814
Name:IZEVBAYE, IYARE E (MBBS)
Entity Type:Individual
Prefix:
First Name:IYARE
Middle Name:E
Last Name:IZEVBAYE
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 BUCHANAN WAY NW
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:ALBERTA
Mailing Address - Zip Code:T6G2B7
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3031
Practice Address - Country:US
Practice Address - Phone:780-983-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105698207ZP0007X
MN54450207ZP0007X
390200000X390200000X
390200000X
GA91802207ZP0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MN220001561Medicare PIN