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General NPI Number Information
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NPI Number | 1740332212
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Entity Type | Individual
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Provider Name | JUSTIN H EZELL D.O.
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Gender | Male
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 07/23/2024
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Provider Practice Location Address
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Address Line | 1320 HEMPHILL ST STE 300
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City | FORT WORTH
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State | TX
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Zip | 76104-4716
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Country | US
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Telephone | 817-336-1189
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Fax |
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Provider Business Mailing Address
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Address Line | 4201 CAMP BOWIE BLVD
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City | FORT WORTH
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State | TX
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Zip | 76107-3928
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Country | US
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Telephone | 817-731-0801
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Fax | 817-731-8468
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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 | 204D00000X
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Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
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License Number | BP10057446
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1068202
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R7207
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License Number State | TX
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