Provider Demographics
NPI:1558333096
Name:JOHNSON, EZRA LAMONT (COTA)
Entity Type:Individual
Prefix:MR
First Name:EZRA
Middle Name:LAMONT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CARVER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-7010
Mailing Address - Country:US
Mailing Address - Phone:910-450-4750
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL CAMP LEJEUNE
Practice Address - Street 2:100 BREWSTER BLVD
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547
Practice Address - Country:US
Practice Address - Phone:910-450-4750
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other