Provider Demographics
NPI:1700091451
Name:IBAZEBO, WESLEY ROBERT (MD)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:ROBERT
Last Name:IBAZEBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1130 N CHURCH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1041
Mailing Address - Country:US
Mailing Address - Phone:336-375-2300
Mailing Address - Fax:336-375-2313
Practice Address - Street 1:1130 N CHURCH ST STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1041
Practice Address - Country:US
Practice Address - Phone:336-375-2300
Practice Address - Fax:336-375-2313
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-00747208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914849Medicaid
NC660860Medicare UPIN