Basic Information
| Provider Information | |||||||||
| NPI: | 1598743254 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EZEANOLUE | ||||||||
| FirstName: | ECHEZONA | ||||||||
| MiddleName: | EDOZIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 W CHARLESTON BLVD | ||||||||
| Address2: | #215 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026712355 | ||||||||
| FaxNumber: | 7023825388 | ||||||||
| Practice Location | |||||||||
| Address1: | 3006 S MARYLAND PKWY | ||||||||
| Address2: | 315 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029926868 | ||||||||
| FaxNumber: | 7029926860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 12/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | 11027 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | BE8170526 | 01 | NV | DEA | OTHER | 100506925 | 05 | NV | MEDICAID | CS13694 | 01 | NV | STATE PHARMACY | OTHER |