Provider Demographics
NPI:1184085029
Name:EZRA, ALEXANDER G (DC)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:G
Last Name:EZRA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BROAD ST
Mailing Address - Street 2:SUITE 2005
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 BROAD ST
Practice Address - Street 2:SUITE 2005
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-2304
Practice Address - Country:US
Practice Address - Phone:212-792-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012795-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor