Basic Information
| Provider Information | |||||||||
| NPI: | 1639129133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EZELDIN | ||||||||
| FirstName: | ABDUL | ||||||||
| MiddleName: | KADER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 W 40TH AVE STE 5C | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716036962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705341726 | ||||||||
| FaxNumber: | 8705340728 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720153353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017766000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | E3462 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 148801001 | 05 | AR | MEDICAID |