Provider Demographics
NPI:1083601538
Name:EZE, PLACID M (M D)
Entity Type:Individual
Prefix:DR
First Name:PLACID
Middle Name:M
Last Name:EZE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 STARK ROAD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2539
Mailing Address - Country:US
Mailing Address - Phone:662-323-4400
Mailing Address - Fax:662-323-4409
Practice Address - Street 1:900 STARK ROAD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2539
Practice Address - Country:US
Practice Address - Phone:662-323-4400
Practice Address - Fax:662-323-4409
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS192773OtherDIABETES SELF MANAGEMENT TREATMENT CENTER
MS640940768OtherTAX ID COMMERCIAL CARRIER
MS09728046Medicaid
MS00122361Medicaid
MS640940768OtherTAX ID COMMERCIAL CARRIER
MS00122361Medicaid
MSC02942Medicare ID - Type UnspecifiedGROUP