Provider Demographics
NPI:1366421372
Name:EZEKWUECHE, CHRISTIAN M (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:M
Last Name:EZEKWUECHE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 PINE ST
Mailing Address - Street 2:SUITE 560
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2173
Mailing Address - Country:US
Mailing Address - Phone:478-741-5155
Mailing Address - Fax:478-746-9682
Practice Address - Street 1:770 PINE ST
Practice Address - Street 2:SUITE 560
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2173
Practice Address - Country:US
Practice Address - Phone:478-741-5155
Practice Address - Fax:478-746-9682
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024808174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29428Medicare UPIN
GA2150196AMedicare ID - Type Unspecified
GA00259949AMedicare ID - Type Unspecified