Basic Information
Provider Information | |||||||||
NPI: | 1679523807 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EZELL | ||||||||
FirstName: | LARRY | ||||||||
MiddleName: | DON | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 620 ECOLLEGE STREET | ||||||||
Address2: |   | ||||||||
City: | HOMER | ||||||||
State: | LA | ||||||||
PostalCode: | 71040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3189272024 | ||||||||
FaxNumber: | 3189273723 | ||||||||
Practice Location | |||||||||
Address1: | 620 ECOLLEGE STREET | ||||||||
Address2: |   | ||||||||
City: | HOMER | ||||||||
State: | LA | ||||||||
PostalCode: | 71040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3189272024 | ||||||||
FaxNumber: | 3189273723 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2006 | ||||||||
LastUpdateDate: | 03/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | C7023 | AR | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207Q00000X | C7023 | AR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 112238001 | 05 | AR |   | MEDICAID | 50503 | 01 | AR | BLUE SHIELD | OTHER | 1884219 | 05 | LA |   | MEDICAID | MD203522 | 01 | LA | LOUISIANA LICENSE | OTHER |