Provider Demographics
NPI:1295851970
Name:EZELL, ANTHONY JAY (COTAL)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JAY
Last Name:EZELL
Suffix:
Gender:M
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9230 BERRYTOWN RD SE
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39653-9035
Mailing Address - Country:US
Mailing Address - Phone:601-384-1562
Mailing Address - Fax:
Practice Address - Street 1:113 MAIN ST.
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MS
Practice Address - Zip Code:39653
Practice Address - Country:US
Practice Address - Phone:601-384-1898
Practice Address - Fax:601-384-1878
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA1041224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant