Provider Demographics
NPI:1710608344
Name:MADESTIN, EZECHIEL
Entity Type:Individual
Prefix:
First Name:EZECHIEL
Middle Name:
Last Name:MADESTIN
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 1:5459 QUEENSHIP CT
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-5970
Mailing Address - Country:US
Mailing Address - Phone:561-574-0851
Mailing Address - Fax:
Practice Address - Street 1:5459 QUEENSHIP CT
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-5970
Practice Address - Country:US
Practice Address - Phone:561-574-0851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021815363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health