Provider Demographics
NPI:1700480829
Name:EZEOKA, VIDAH IFEOMA
Entity Type:Individual
Prefix:MRS
First Name:VIDAH
Middle Name:IFEOMA
Last Name:EZEOKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S GESSNER RD STE 270
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-3200
Mailing Address - Country:US
Mailing Address - Phone:832-607-4083
Mailing Address - Fax:
Practice Address - Street 1:2600 S GESSNER RD STE 270
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-3200
Practice Address - Country:US
Practice Address - Phone:832-607-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1019882363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health