=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164709036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABDUL EZELDIN M.D. P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2011
-----------------------------------------------------
Last Update Date | 03/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 W 40TH AVE STE 5C
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71603-6962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-534-1726
-----------------------------------------------------
Fax | 870-534-0728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 W 40TH AVE STE 5C P. O BOX 1446
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71603-6962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-534-1726
-----------------------------------------------------
Fax | 870-534-0728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ABDUL K EZELDIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 870-534-1726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | BE5718739
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------