MEDICARE: OSITA VICTOR EZEAKUDO M.D.

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	208000000X	Pediatrics Physician	01065437A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013078351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OSITA VICTOR EZEAKUDO M.D.

Provider Business Mailing Address
First Line	:	2518 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1675
Country	:	US
Telephone Number	:	260-432-4400
Fax Number	:	260-969-6833

Provider Business Practice Location Address
First Line	:	2510 E DUPONT RD
Second Line	:	SUITE 200
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1601
Country	:	US
Telephone Number	:	260-432-4913
Fax Number	:	260-969-6832

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	01/14/2026

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