Provider Demographics
NPI:1053684340
Name:EZADHE, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:EZADHE
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 1:151 JERSEY STREET
Mailing Address - Street 2:APT.1D
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301
Mailing Address - Country:US
Mailing Address - Phone:347-785-3270
Mailing Address - Fax:
Practice Address - Street 1:151 JERSEY ST
Practice Address - Street 2:APT.1D
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-1464
Practice Address - Country:US
Practice Address - Phone:347-785-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306157-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse