Provider Demographics
NPI:1154615979
Name:IBEZI-ENENDU, ALEXANDER CHUKWUMA (DO)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:CHUKWUMA
Last Name:IBEZI-ENENDU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 8203
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31095-8203
Mailing Address - Country:US
Mailing Address - Phone:478-355-3000
Mailing Address - Fax:478-355-3001
Practice Address - Street 1:2809 PINE ST
Practice Address - Street 2:
Practice Address - City:UNADILLA
Practice Address - State:GA
Practice Address - Zip Code:31091-7701
Practice Address - Country:US
Practice Address - Phone:478-355-3000
Practice Address - Fax:478-355-3001
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019441207P00000X
GA75636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003167544BMedicaid