Provider Demographics
NPI:1407816911
Name:EZEANI, IFEOMA LAWRETTA (OD)
Entity type:Individual
Prefix:MRS
First Name:IFEOMA
Middle Name:LAWRETTA
Last Name:EZEANI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 VIA CARDELINA
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATE
Mailing Address - State:CA
Mailing Address - Zip Code:90274
Mailing Address - Country:US
Mailing Address - Phone:310-378-0291
Mailing Address - Fax:310-469-8304
Practice Address - Street 1:20763 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746
Practice Address - Country:US
Practice Address - Phone:310-464-8300
Practice Address - Fax:310-464-8304
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12478T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U99057Medicare UPIN
CAOP12478Medicare ID - Type Unspecified