Healthcare Provider Details

I. General information

NPI: 1871750539
Provider Name (Legal Business Name): NGOZI IHEUWA EZEH MD, RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 EISENHOWER PKWY
MACON GA
31206-0800
US

IV. Provider business mailing address

147 THE MASTERS CV
MACON GA
31211-6005
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-0550
  • Fax:
Mailing address:
  • Phone: 478-257-6672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number006375-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00054000
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number003567
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: