Provider Demographics
NPI:1053547919
Name:EZEANYA, EBERE N (MD)
Entity type:Individual
Prefix:DR
First Name:EBERE
Middle Name:N
Last Name:EZEANYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 CITY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-1244
Mailing Address - Country:US
Mailing Address - Phone:973-704-5644
Mailing Address - Fax:
Practice Address - Street 1:445 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2695
Practice Address - Country:US
Practice Address - Phone:609-582-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD469728207Q00000X
NJ25MA09219400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0357367Medicaid