Provider Demographics
NPI:1972743946
Name:EZEIGBO, EDITH
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:EZEIGBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-7436
Mailing Address - Country:US
Mailing Address - Phone:770-471-3487
Mailing Address - Fax:
Practice Address - Street 1:500 W LANIER AVE
Practice Address - Street 2:BUILDING 200, SUITE 202
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7636
Practice Address - Country:US
Practice Address - Phone:770-471-3487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies