Provider Demographics
NPI:1639889504
Name:MCFADDEN, EZZARD LEE
Entity Type:Individual
Prefix:
First Name:EZZARD
Middle Name:LEE
Last Name:MCFADDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 NW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-2325
Mailing Address - Country:US
Mailing Address - Phone:954-919-8040
Mailing Address - Fax:
Practice Address - Street 1:18 NW 8TH ST
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-2325
Practice Address - Country:US
Practice Address - Phone:954-919-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2024MT513591343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)