Provider Demographics
NPI:1942499439
Name:EZELL, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:EZELL
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 1:4384 MILAM RD
Mailing Address - Street 2:
Mailing Address - City:BATES CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64011-8287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4384 MILAM RD
Practice Address - Street 2:
Practice Address - City:BATES CITY
Practice Address - State:MO
Practice Address - Zip Code:64011-8287
Practice Address - Country:US
Practice Address - Phone:816-690-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine Technology