Provider Demographics
NPI:1033747225
Name:FOX, EZRA
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:
Last Name:FOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2952 W BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1220
Mailing Address - Country:US
Mailing Address - Phone:773-465-4238
Mailing Address - Fax:
Practice Address - Street 1:LAKELAND HEALTH- GME
Practice Address - Street 2:1234 NAPIER AVENUE
Practice Address - City:ST. JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-982-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program