Provider Demographics
NPI:1851617757
Name:COLE, EZRA LEE (MD)
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:LEE
Last Name:COLE
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:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-0516
Mailing Address - Country:US
Mailing Address - Phone:479-549-4228
Mailing Address - Fax:479-549-3711
Practice Address - Street 1:1101 N PROGRESS AVE
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-4343
Practice Address - Country:US
Practice Address - Phone:479-549-4228
Practice Address - Fax:479-549-3711
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE8536208000000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR203868001Medicaid
OK200303500BMedicaid
AR203868001Medicaid