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Justin H Ezell

Family Medicine

Allopathic & Osteopathic Physicians

1320 Hemphill St Ste 300, Fort Worth, TX 76104-4716

PECOS Enrollment

This provider is enrolled in PECOS as JUSTIN EZELL.

Based on the most recent information from CMS, provider Justin H Ezell is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.

Part B
Medicare Part B
Enrolled
HHA
Home Health Agency
Enrolled
DME
Durable Medical Equipment
Enrolled
PMD
Power Mobility Device
Enrolled

CMS last updated its PECOS records 3 days ago.

Profile Details

Provider ID
1740332212
Provider Type
Individual
Full Name
Ezell, Justin H
Credential
D.O.

Gender
Male
Sole Proprietor
No
Enumeration Date
1/17/2007
Last Updated
7/23/2024

Contact Information

Practice Location

1320 Hemphill St Ste 300, Fort Worth, TX 76104-4716

(817) 336-1189

Unlisted Fax

Mailing Location

4201 Camp Bowie Blvd, Fort Worth, TX 76107-3928

(817) 731-0801

(817) 731-8468

Provider Taxonomies

Code	Description	License
Code 207Q00000X Primary	Description Family Medicine Allopathic & Osteopathic Physicians	License R7207 Texas
Code 204D00000X	Description Neuromusculoskeletal Medicine & OMM Allopathic & Osteopathic Physicians	License BP10057446 Texas
Code 363A00000X	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License 1068202

Provider Identifiers

ID	Description	Issuer
ID 291361802	Description Medicaid	Issuer Unlisted Texas
ID 291361801	Description Medicaid	Issuer Unlisted Texas
ID 291361803	Description Medicaid	Issuer Unlisted Texas

Justin H Ezell

PECOS Enrollment

Profile Details

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