Healthcare Provider Details

I. General information

NPI: 1790365625
Provider Name (Legal Business Name): DANIEL RAYMOND EZZO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 CHESTNUT ST STE 210
PHILADELPHIA PA
19107-4405
US

IV. Provider business mailing address

833 CHESTNUT ST STE 210
PHILADELPHIA PA
19107-4405
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-8420
  • Fax: 215-503-0429
Mailing address:
  • Phone: 215-955-5638
  • Fax: 215-503-6116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD486725
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: