=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609939347
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN ENYINNA OKEZIE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2006
-----------------------------------------------------
Last Update Date | 10/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 972 E 133RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60827-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-291-0035
-----------------------------------------------------
Fax | 773-291-0037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3124 KATHLEEN LN
-----------------------------------------------------
City | FLOSSMOOR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60422-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-291-0035
-----------------------------------------------------
Fax | 773-291-0037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036056093
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------