Basic Information
| Provider Information | |||||||||
| NPI: | 1578139325 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | IBEZIM | ||||||||
| FirstName: | GINIKACHUKWU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DELL SETON MEDICAL CENTER 1400 N-IH 35 | ||||||||
| Address2: | STE C2.410 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123247318 | ||||||||
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| Practice Location | |||||||||
| Address1: | DELL SETON MEDICAL CENTER 1400 N-IH 35 | ||||||||
| Address2: | STE C2.410 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123247318 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2021 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10076141 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.