MEDICARE: OBIANUJU CHINONYE EZIOLISA DO

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	207P00000X	Emergency Medicine Physician	T5883	TX
2	207P00000X	Emergency Medicine Physician	2023027333	MO

General Provider Information

NPI Number	:	1679033039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OBIANUJU CHINONYE EZIOLISA DO

Provider Business Mailing Address
First Line	:	6431 FANNIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1501
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6411 FANNIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1501
Country	:	US
Telephone Number	:	713-500-7885
Fax Number	:	713-500-0625

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

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	03/02/2026

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