Provider Demographics
NPI:1790255826
Name:EZEONU, JIDEOBI Y (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JIDEOBI
Middle Name:Y
Last Name:EZEONU
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 SUWANEE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-1635
Mailing Address - Country:US
Mailing Address - Phone:908-202-7342
Mailing Address - Fax:
Practice Address - Street 1:3391 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2025
Practice Address - Country:US
Practice Address - Phone:908-202-7342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-02
Last Update Date:2018-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023127-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist