Provider Demographics
NPI:1992703813
Name:EZE, AUGUSTINE R (MD)
Entity type:Individual
Prefix:MR
First Name:AUGUSTINE
Middle Name:R
Last Name:EZE
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 1:825 MAJESTIC CT STE F
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5190
Mailing Address - Country:US
Mailing Address - Phone:704-864-6500
Mailing Address - Fax:704-864-0101
Practice Address - Street 1:825 MAJESTIC CT STE F
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5190
Practice Address - Country:US
Practice Address - Phone:704-864-6500
Practice Address - Fax:704-864-0104
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600205208600000X
NC9000205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900575Medicaid
NC5900575Medicaid
NC2228857FMedicare ID - Type Unspecified
SCF417448386Medicare PIN