Provider Demographics
NPI:1033386230
Name:EZELL, THEO HOWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:THEO
Middle Name:HOWARD
Last Name:EZELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:THEO
Other - Middle Name:HOWARD
Other - Last Name:EZELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:525 RIVERGATE PKWY
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-2078
Mailing Address - Country:US
Mailing Address - Phone:615-859-1928
Mailing Address - Fax:
Practice Address - Street 1:525 RIVERGATE PKWY
Practice Address - Street 2:SUITE # 2
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2078
Practice Address - Country:US
Practice Address - Phone:615-859-1928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD 493152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist