Provider Demographics
NPI:1669426672
Name:NEIMARK, EZEQUIEL (MD)
Entity type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:
Last Name:NEIMARK
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 1:593 EDDY STREET
Mailing Address - Street 2:MPH - 131
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903
Mailing Address - Country:US
Mailing Address - Phone:401-444-6484
Mailing Address - Fax:401-444-6378
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-8306
Practice Address - Fax:401-444-8748
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI117152080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIEN58363Medicaid
RII42408Medicare UPIN
RI007057936Medicare PIN