Provider Demographics
NPI:1700827136
Name:EJAZ, ABUTALEB A (MD)
Entity Type:Individual
Prefix:
First Name:ABUTALEB
Middle Name:A
Last Name:EJAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ABUTALEB
Other - Middle Name:AHSAN
Other - Last Name:EJAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8040
Mailing Address - Fax:443-462-3514
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1590
Practice Address - Country:US
Practice Address - Phone:410-328-5720
Practice Address - Fax:410-328-5685
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD41682207R00000X, 207RN0300X
FLME67226207RN0300X
VA0101264739207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259116200Medicaid
26184XMedicare PIN
FL259116200Medicaid