Healthcare Provider Details

I. General information

NPI: 1023612363
Provider Name (Legal Business Name): CHIKE C EZEJIOFOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2020
Last Update Date: 11/27/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10106 DORSEY LN
LANHAM MD
20706-2567
US

IV. Provider business mailing address

10106 DORSEY LN
LANHAM MD
20706-2567
US

V. Phone/Fax

Practice location:
  • Phone: 240-825-8933
  • Fax:
Mailing address:
  • Phone: 240-825-8933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number012287
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: