Provider Demographics
NPI:1881789188
Name:NIELSEN, EZRA SCOTT (MD)
Entity type:Individual
Prefix:
First Name:EZRA
Middle Name:SCOTT
Last Name:NIELSEN
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 636
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:CA
Mailing Address - Zip Code:93212-0636
Mailing Address - Country:US
Mailing Address - Phone:559-992-0082
Mailing Address - Fax:559-992-9873
Practice Address - Street 1:1310 HANNA AVE
Practice Address - Street 2:STE 1
Practice Address - City:CORCORAN
Practice Address - State:CA
Practice Address - Zip Code:93212-2314
Practice Address - Country:US
Practice Address - Phone:559-992-0082
Practice Address - Fax:559-992-9873
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A441460Medicaid
CAA76349Medicare UPIN
CA00A441460Medicare PIN