MEDICARE: DR. EHIREME ANTHONY IBAZEBO 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	2084P0800X	Psychiatry Physician	C156633	CA
2	2084P0800X	Psychiatry Physician	K9571	TX

General Provider Information

NPI Number	:	1639373731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EHIREME ANTHONY IBAZEBO MD

Provider Business Mailing Address
First Line	:	2300 MCDERMOTT RD
Second Line	:	SUITE 200-349
City	:	PLANO
State	:	TX
Zip	:	75025-7016
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 N STEMMONS FWY
Second Line	:	SUITE 151
City	:	DALLAS
State	:	TX
Zip	:	75207-2113
Country	:	US
Telephone Number	:	214-905-0595
Fax Number	:

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

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	11/18/2020

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