Healthcare Provider Details

I. General information

NPI: 1003470295
Provider Name (Legal Business Name): CHIZITAM IBEZIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 PALUXY RD STE 3000
GRANBURY TX
76048-5655
US

IV. Provider business mailing address

1310 PALUXY RD STE 3000
GRANBURY TX
76048-5655
US

V. Phone/Fax

Practice location:
  • Phone: 817-579-2020
  • Fax: 817-579-3909
Mailing address:
  • Phone: 817-579-2020
  • Fax: 817-579-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036174858
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01096132A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number036174858
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number01096132A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: