Healthcare Provider Details

I. General information

NPI: 1568802148
Provider Name (Legal Business Name): CHIZOBA JOAKIN EZEPUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12266 DE PAUL DR STE 100
BRIDGETON MO
63044-2541
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-2500
US

V. Phone/Fax

Practice location:
  • Phone: 314-738-2770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number71351
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number2017020334
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number036148557
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: