Provider Demographics
NPI:1760670517
Name:EZEA D. EDE MD
Entity Type:Organization
Organization Name:EZEA D. EDE MD
Other - Org Name:OCHENDU MEDICAL CLINIC PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EZEA
Authorized Official - Middle Name:D
Authorized Official - Last Name:EDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-832-6129
Mailing Address - Street 1:740 HOSPITAL DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4664
Mailing Address - Country:US
Mailing Address - Phone:409-832-6129
Mailing Address - Fax:409-832-6240
Practice Address - Street 1:740 HOSPITAL DR
Practice Address - Street 2:SUITE 230
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4664
Practice Address - Country:US
Practice Address - Phone:409-832-6129
Practice Address - Fax:409-832-6240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128213903Medicaid
TX128213903Medicaid