MEDICARE: DR. FIDELIS IFEANYI EZEWIKE JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS56304	FL

General Provider Information

NPI Number	:	1003395955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FIDELIS IFEANYI EZEWIKE JR.

Provider Business Mailing Address
First Line	:	17355 SW 33RD CT
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33029-2606
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2034 PALM PLACE DR NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-3960
Country	:	US
Telephone Number	:	954-224-8205
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2018
Last Update Date	:	08/11/2018

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