Provider Demographics
NPI:1407843774
Name:EZZ, AHMED E (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMED
Middle Name:E
Last Name:EZZ
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:28595 ORCHARD LAKE RD
Practice Address - Street 2:#110
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2977
Practice Address - Country:US
Practice Address - Phone:248-553-0606
Practice Address - Fax:248-553-7674
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010608642085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4711299Medicaid
MI101715OtherCARE CHOICES HMO PROV. #
MI300041558OtherRAILROAD MEDICARE
MA3057642Medicaid
F81594Medicare UPIN
MA3057642Medicaid
MI101715OtherCARE CHOICES HMO PROV. #