Healthcare Provider Details

I. General information

NPI: 1669426672
Provider Name (Legal Business Name): EZEQUIEL NEIMARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY STREET MPH - 131
PROVIDENCE RI
02903
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-8306
  • Fax: 401-444-8748
Mailing address:
  • Phone: 401-444-6484
  • Fax: 401-444-6378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number11715
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: