Provider Demographics
NPI:1174509335
Name:EZEKOWITZ, R ALAN (MBCH DPHL)
Entity Type:Individual
Prefix:DR
First Name:R
Middle Name:ALAN
Last Name:EZEKOWITZ
Suffix:
Gender:M
Credentials:MBCH DPHL
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:WAC 7 PEDIATRIC MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-2900
Practice Address - Fax:617-726-4466
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA57810208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA057810OtherTUFTS HEALTH PLAN
MA3030211Medicaid
MAJ07147OtherBCBS MA
MA3030211Medicaid
MAJ07147OtherBCBS MA