Healthcare Provider Details

I. General information

NPI: 1215053582
Provider Name (Legal Business Name): KANAYO AFAMEFINA EZEANOLUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W. CHARLESTON BLVD.
LAS VEGAS NV
89102
US

IV. Provider business mailing address

1800 W. CHARLESTON BLVD. STE. 508
LAS VEGAS NV
89102
US

V. Phone/Fax

Practice location:
  • Phone: 702-383-2000
  • Fax: 313-745-5867
Mailing address:
  • Phone: 702-383-2688
  • Fax: 702-671-6595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301093717
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number14287
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: