Provider Demographics
NPI:1245336171
Name:MARSHALL, EZRA (MD)
Entity type:Individual
Prefix:
First Name:EZRA
Middle Name:
Last Name:MARSHALL
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 1:1451 BINNEY DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3109
Mailing Address - Country:US
Mailing Address - Phone:772-332-2251
Mailing Address - Fax:
Practice Address - Street 1:1451 BINNEY DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34949-3109
Practice Address - Country:US
Practice Address - Phone:772-332-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58047Medicare UPIN