Provider Demographics
NPI:1992352934
Name:EZE-RAPHAEL, CHINENYE U (MD)
Entity type:Individual
Prefix:
First Name:CHINENYE
Middle Name:U
Last Name:EZE-RAPHAEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHINENYE
Other - Middle Name:U
Other - Last Name:OGUEJIOFOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-676-4102
Practice Address - Fax:812-676-4106
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01087442A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program