Provider Demographics
NPI:1700883014
Name:EZEANOLUE, DOLUE DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DOLUE
Middle Name:DAVID
Last Name:EZEANOLUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 BEARDEN DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4189
Mailing Address - Country:US
Mailing Address - Phone:702-310-9110
Mailing Address - Fax:702-310-9114
Practice Address - Street 1:1701 BEARDEN DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4189
Practice Address - Country:US
Practice Address - Phone:702-310-9110
Practice Address - Fax:702-310-9114
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2017-09-12
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-07-10
Provider Licenses
StateLicense IDTaxonomies
NV8421207R00000X, 208100000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019939Medicaid
NVNV7125OtherBLUE CROSS BLUE SHIELD
NVV32614Medicare PIN
NV002019939Medicaid