Provider Demographics
NPI:1760010649
Name:EZEBILO, IJEAMAKA (MD)
Entity Type:Individual
Prefix:
First Name:IJEAMAKA
Middle Name:
Last Name:EZEBILO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W JACKSON ST DEPT OF
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1467
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:410-554-2184
Practice Address - Street 1:405 W JACKSON ST DEPT OF
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1467
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036164272207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine