Provider Demographics
NPI:1891011201
Name:DETROY, EZRA M (MD)
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:M
Last Name:DETROY
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 1:589 CHAPEL ST # 2
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6919
Mailing Address - Country:US
Mailing Address - Phone:203-984-1420
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT540632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program