Provider Demographics
NPI:1306478334
Name:EZEOKONKWO, MELVIN CHIZOBA
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:CHIZOBA
Last Name:EZEOKONKWO
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 1:8162 BIRCH WALK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-7116
Mailing Address - Country:US
Mailing Address - Phone:770-912-4515
Mailing Address - Fax:
Practice Address - Street 1:8162 BIRCH WALK DR
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-7116
Practice Address - Country:US
Practice Address - Phone:770-912-4515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer