Provider Demographics
NPI:1932412509
Name:EZIDINMA, AFOMA PHOEBE (MD)
Entity Type:Individual
Prefix:DR
First Name:AFOMA
Middle Name:PHOEBE
Last Name:EZIDINMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PHOEBE
Other - Middle Name:A
Other - Last Name:EZIDINMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:836 W WELLINGTON AVE
Mailing Address - Street 2:# 1423
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5147
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:5605 E ROCKTON RD
Practice Address - Street 2:NORTHPOINTE CLINIC
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7601
Practice Address - Country:US
Practice Address - Phone:815-525-4500
Practice Address - Fax:815-525-4505
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036122956207R00000X, 208M00000X
IL036-122956207RC0000X
WI56346-20207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370340010Medicare PIN