Provider Demographics
NPI:1376502518
Name:EZEKIEL, MARK PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PATRICK
Last Name:EZEKIEL
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 1:298 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-2953
Mailing Address - Country:US
Mailing Address - Phone:803-321-3232
Mailing Address - Fax:803-321-3234
Practice Address - Street 1:298 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2953
Practice Address - Country:US
Practice Address - Phone:803-321-3232
Practice Address - Fax:803-321-3234
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC214402085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8965OtherMEDICARE PTAN
SC214404Medicaid
SC21440OtherLICENSE
SC8965OtherMEDICARE PTAN