Provider Demographics
NPI:1235130741
Name:EZELL, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:EZELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 W CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-2700
Mailing Address - Country:US
Mailing Address - Phone:610-446-2260
Mailing Address - Fax:610-446-3360
Practice Address - Street 1:2010 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2700
Practice Address - Country:US
Practice Address - Phone:610-446-2260
Practice Address - Fax:610-446-3360
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025524E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00420778OtherRAILROAD MEDICARE
PA134646K3SMedicare PIN
PAB38097Medicare UPIN