=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588318638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON COUNTY PUBLIC HEALTH DEPT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2022
-----------------------------------------------------
Last Update Date | 02/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1295 PEARL ST
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77701-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-839-2307
-----------------------------------------------------
Fax | 409-839-2302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1295 PEARL ST
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77701-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-839-2307
-----------------------------------------------------
Fax | 409-839-2302
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/DOCTOR
-----------------------------------------------------
Name | DR. EZEA D EDE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 409-835-8530
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------