Provider Demographics
NPI:1063582575
Name:EZEMONYE, GOZIE TONY
Entity type:Individual
Prefix:
First Name:GOZIE
Middle Name:TONY
Last Name:EZEMONYE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90251-0086
Mailing Address - Country:US
Mailing Address - Phone:310-676-0576
Mailing Address - Fax:310-676-9109
Practice Address - Street 1:4448 W.EL SEGUNDO BL.
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-4421
Practice Address - Country:US
Practice Address - Phone:310-676-0576
Practice Address - Fax:310-676-9109
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101671332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1322530001Medicare ID - Type Unspecified