Provider Demographics
NPI:1083141899
Name:EBOT, JAMES (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:EBOT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742712
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2712
Mailing Address - Country:US
Mailing Address - Phone:877-866-7123
Mailing Address - Fax:
Practice Address - Street 1:17218 PRESTON RD STE 2000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-4018
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO5370207T00000X
TXT2156207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX435784001Medicaid