Basic Information
| Provider Information | |||||||||
| NPI: | 1740829738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BENNETT J EZEKIEL MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791 | ||||||||
| Address2: | |||||||||
| City: | CARNEGIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151060791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126554362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 351 SETON PKWY | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786658001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125419217 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2019 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | BILLINGS | ||||||||
| AuthorizedOfficialFirstName: | KRISTYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4126554362 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | N6287 | 01 | TX | STATE LICENSE | OTHER |