Provider Demographics
NPI:1962829424
Name:EZZAT, IMAAN
Entity Type:Individual
Prefix:
First Name:IMAAN
Middle Name:
Last Name:EZZAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30-02 39TH AVENUE IMAAN EZZAT
Mailing Address - Street 2:APARTMENT A-728
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101
Mailing Address - Country:US
Mailing Address - Phone:507-319-8916
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH STREET LINCOLN HOSPITAL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451
Practice Address - Country:US
Practice Address - Phone:718-579-4657
Practice Address - Fax:718-579-4744
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-23
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist