Provider Demographics
NPI:1740332212
Name:EZELL, JUSTIN H (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:H
Last Name:EZELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3928
Mailing Address - Country:US
Mailing Address - Phone:817-731-0801
Mailing Address - Fax:817-731-8468
Practice Address - Street 1:1320 HEMPHILL ST STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4716
Practice Address - Country:US
Practice Address - Phone:817-336-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10057446204D00000X, 207Q00000X
1068202363A00000X
TXR7207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX291361802Medicaid
TX291361801Medicaid
TX291361803Medicaid