Provider Demographics
NPI:1033144241
Name:CASSINELLI, EZEQUIEL HERNAN (MD)
Entity Type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:HERNAN
Last Name:CASSINELLI
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 1:2001 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 705
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1476
Mailing Address - Country:US
Mailing Address - Phone:404-355-0743
Mailing Address - Fax:404-355-2136
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 600
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1705
Practice Address - Country:US
Practice Address - Phone:404-355-0743
Practice Address - Fax:404-943-0641
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059053207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0486290001OtherDME
000000503683OtherANTHEM
OHP00242139OtherRAILROAD MEDICARE
203287OtherUNISON
P00364266OtherMCR RR
OH2409521Medicaid
7848618OtherAETNA
RRBCB4505Medicare PIN
203287OtherUNISON
H81499Medicare UPIN
OHCA4166335Medicare ID - Type Unspecified