Healthcare Provider Details

I. General information

NPI: 1215105853
Provider Name (Legal Business Name): MARY BROOKES EZELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 TULANE AVE # SL-54
NEW ORLEANS LA
70112-2632
US

IV. Provider business mailing address

1118 ORANGE ST APT 1
NEW ORLEANS LA
70130-4735
US

V. Phone/Fax

Practice location:
  • Phone: 504-988-2651
  • Fax:
Mailing address:
  • Phone: 504-610-4137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number201394
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD.201394
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: