Healthcare Provider Details

I. General information

NPI: 1992352934
Provider Name (Legal Business Name): CHINENYE U EZE-RAPHAEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHINENYE U OGUEJIOFOR

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 E DISCOVERY PKWY
BLOOMINGTON IN
47408-9059
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4102
  • Fax: 812-676-4106
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01087442A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: