Provider Demographics
NPI:1679523807
Name:EZELL, LARRY DON (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:DON
Last Name:EZELL
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 1:620 ECOLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:LA
Mailing Address - Zip Code:71040
Mailing Address - Country:US
Mailing Address - Phone:318-927-2024
Mailing Address - Fax:318-927-3723
Practice Address - Street 1:620 ECOLLEGE STREET
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:LA
Practice Address - Zip Code:71040
Practice Address - Country:US
Practice Address - Phone:318-927-2024
Practice Address - Fax:318-927-3723
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7023207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112238001Medicaid
AR50503OtherBLUE SHIELD
LA1884219Medicaid
LAMD203522OtherLOUISIANA LICENSE
AR112238001Medicaid
LAMD203522OtherLOUISIANA LICENSE
LA1884219Medicaid