Provider Demographics
NPI:1821068420
Name:NZEOGU, IKENNA S (DO)
Entity Type:Individual
Prefix:DR
First Name:IKENNA
Middle Name:S
Last Name:NZEOGU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:388 BEN BOLT AVE
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-5386
Practice Address - Country:US
Practice Address - Phone:276-988-8740
Practice Address - Fax:276-988-5941
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3039207Q00000X, 207P00000X
KY04652207P00000X
VA0102203356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000378682OtherBLUECROSS BLUESHIELD
OH2048153Medicaid
OH000000527464OtherANTHEM BCBS
G75952Medicare UPIN
OHNZ4193243Medicare PIN
OH0869024Medicare UPIN
OH2048153Medicaid
OH000000527464OtherANTHEM BCBS
OH000000378682OtherBLUECROSS BLUESHIELD
OHNZ0869028Medicare PIN