Provider Demographics
NPI:1053413435
Name:BEN-EZRA, JEFFREY MARK
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:MARK
Last Name:BEN-EZRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 VILLAGE COURT
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730
Mailing Address - Country:US
Mailing Address - Phone:732-888-0595
Mailing Address - Fax:732-888-8351
Practice Address - Street 1:24 VILLAGE COURT
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730
Practice Address - Country:US
Practice Address - Phone:732-888-0595
Practice Address - Fax:732-888-8351
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00463200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6455603Medicaid
NJ6455603Medicaid