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General NPI Number Information
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NPI Number | 1699770990
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Entity Type | Individual
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Provider Name | JOHN EZRA TRAINER III M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/15/2005
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Last Update Date | 12/02/2022
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Provider Practice Location Address
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Address Line | 6841 BLANDING BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32244-4418
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Country | US
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Telephone | 904-862-2175
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Fax | 904-862-2175
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Provider Business Mailing Address
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Address Line | 6841 BLANDING BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32244-4418
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Country | US
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Telephone | 904-862-2175
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Fax | 904-862-2175
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0000X
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Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
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License Number | ME80458
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME80458
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License Number State | FL
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