Healthcare Provider Details

I. General information

NPI: 1922590264
Provider Name (Legal Business Name): EZRA HOOVER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2018
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 E STATE ST
ATHENS OH
45701-2138
US

IV. Provider business mailing address

1151 CHADBYRNE DR
COLUMBUS OH
43235-1790
US

V. Phone/Fax

Practice location:
  • Phone: 740-566-4621
  • Fax:
Mailing address:
  • Phone: 347-259-8477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number34.016061
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: