Provider Demographics
NPI:1659834695
Name:HARTMAN, EZEKIEL DONOVAN
Entity type:Individual
Prefix:
First Name:EZEKIEL
Middle Name:DONOVAN
Last Name:HARTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 REGENCY PL
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-4859
Mailing Address - Country:US
Mailing Address - Phone:815-541-5774
Mailing Address - Fax:
Practice Address - Street 1:5510 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2946
Practice Address - Country:US
Practice Address - Phone:563-424-2025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2024-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IAMD-52710208000000X
OH57.248047208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program