Provider Demographics
NPI:1205996402
Name:YOUSEF, EJAZ (MD)
Entity type:Individual
Prefix:DR
First Name:EJAZ
Middle Name:
Last Name:YOUSEF
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC, JACKSONVILLE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:904-697-3455
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI565792080P0201X, 207K00000X
FLME1209082080P0201X
DEC100061352080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013670600Medicaid
GA0033153424BMedicaid
NJ8003700Medicaid
MD8301018Medicaid
WI1205996402Medicaid
KY64050859Medicaid
PA001680789Medicaid
FL013670600Medicaid
WI1205996402Medicaid