Basic Information
Provider Information | |||||||||
NPI: | 1699809483 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EZIKE | ||||||||
FirstName: | AGNES | ||||||||
MiddleName: | CHINWE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4299 SAN FELIPE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770272916 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8324763900 | ||||||||
FaxNumber: | 8324763990 | ||||||||
Practice Location | |||||||||
Address1: | 1401 ST. JOSEPH PARKWAY | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770028301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137568537 | ||||||||
FaxNumber: | 7137568538 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2007 | ||||||||
LastUpdateDate: | 12/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/16/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35.089379 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | N0010 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | N0010 | TX | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.