Provider Demographics
NPI:1245435056
Name:AMENE, CHIAZO S (MD, FAANS)
Entity type:Individual
Prefix:DR
First Name:CHIAZO
Middle Name:S
Last Name:AMENE
Suffix:
Gender:F
Credentials:MD, FAANS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 9TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3916
Mailing Address - Country:US
Mailing Address - Phone:817-870-5094
Mailing Address - Fax:
Practice Address - Street 1:909 9TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3916
Practice Address - Country:US
Practice Address - Phone:817-870-5094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014010397207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1245435056Medicaid
MO132680536Medicare PIN