Provider Demographics
NPI:1346239738
Name:EZRIN, MITCHELL ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ROBERT
Last Name:EZRIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 WICKS RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6080 JERICHO TPKE
Practice Address - Street 2:SUITE 206
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2850
Practice Address - Country:US
Practice Address - Phone:631-499-2212
Practice Address - Fax:631-499-2568
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002077111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT52311Medicare UPIN
NYX17471Medicare ID - Type UnspecifiedCHIROPRACTOR