Provider Demographics
NPI:1023312600
Name:ELLEZAM, BENJAMIN (MD, PHD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ELLEZAM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SAINT-JUSTINE HOSPITAL - DEPT PATHOLOGY
Mailing Address - Street 2:3175 COTE-STE-CATHERINE
Mailing Address - City:MONTREAL
Mailing Address - State:QUEBEC
Mailing Address - Zip Code:H3T 1C5
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SAINT-JUSTINE HOSPITAL - DEPT PATHOLOGY
Practice Address - Street 2:3175 COTE-STE-CATHERINE
Practice Address - City:MONTREAL
Practice Address - State:QUEBEC
Practice Address - Zip Code:H3T 1C5
Practice Address - Country:CA
Practice Address - Phone:514-345-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-22
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ12090207ZN0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology