Provider Demographics
NPI:1770688079
Name:EZE, EMMANUEL E (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:E
Last Name:EZE
Suffix:
Gender:M
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:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0650
Mailing Address - Country:US
Mailing Address - Phone:606-329-1016
Mailing Address - Fax:
Practice Address - Street 1:1544 WINCHESTER AVE
Practice Address - Street 2:SUITE 701
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7923
Practice Address - Country:US
Practice Address - Phone:606-329-1016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY318102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2115240Medicaid
KY64318108Medicaid
KYP00133162OtherRAILROAD MEDICARE
KY000000324519OtherBLUE CROSS & BLUE SHIELD
WV0115962001Medicaid
KYP00133162OtherRAILROAD MEDICARE
WV0115962001Medicaid