Provider Demographics
NPI:1679715130
Name:SHOTTS, EZEKIEL ELLIOTT (MD)
Entity type:Individual
Prefix:DR
First Name:EZEKIEL
Middle Name:ELLIOTT
Last Name:SHOTTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S CHURCH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4154
Mailing Address - Country:US
Mailing Address - Phone:870-932-0639
Mailing Address - Fax:870-932-0526
Practice Address - Street 1:225 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3111
Practice Address - Country:US
Practice Address - Phone:870-910-6654
Practice Address - Fax:870-932-0526
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-78452085R0202X
GA003978207R00000X
390200000X
MN534672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN300005768Medicare PIN