Healthcare Provider Details

I. General information

NPI: 1205996402
Provider Name (Legal Business Name): EJAZ YOUSEF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY NEMOURS CHILDRENS CLINIC, JACKSONVILLE
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax: 904-697-3455
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number56579
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberME120908
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number56579
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberC10006135
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: