MEDICARE: WALTER AZUBUIKE EZEIGBO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9601605	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306839659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER AZUBUIKE EZEIGBO MD

Provider Business Mailing Address
First Line	:	1000 SOUTHPARK BLVD
Second Line	:	SUITE A
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-5072
Country	:	US
Telephone Number	:	336-788-4545
Fax Number	:	336-788-4556

Provider Business Practice Location Address
First Line	:	1000 SOUTHPARK BLVD
Second Line	:	SUITE A
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-5072
Country	:	US
Telephone Number	:	336-788-4545
Fax Number	:	336-788-4556

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	02/19/2013

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