Provider Demographics
NPI:1821527649
Name:EZE, CHISOM (MD)
Entity Type:Individual
Prefix:
First Name:CHISOM
Middle Name:
Last Name:EZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:621 S BALLAS RD STE 112A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5314
Mailing Address - Country:US
Mailing Address - Phone:142-516-3393
Mailing Address - Fax:314-251-4564
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6339
Practice Address - Fax:314-251-4564
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS94-09269207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine