Basic Information
| Provider Information | |||||||||
| NPI: | 1164709036 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ABDUL EZELDIN M.D. P.A. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 W 40TH AVE STE 5C | ||||||||
| Address2: | P. O BOX 1446 | ||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716036962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705341726 | ||||||||
| FaxNumber: | 8705340728 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 W 40TH AVE STE 5C | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716036962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705341726 | ||||||||
| FaxNumber: | 8705340728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2011 | ||||||||
| LastUpdateDate: | 03/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | EZELDIN | ||||||||
| AuthorizedOfficialFirstName: | ABDUL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8705341726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | BE5718739 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.