Provider Demographics
NPI:1548270614
Name:HAFEZ, EZZAT (MD)
Entity type:Individual
Prefix:
First Name:EZZAT
Middle Name:
Last Name:HAFEZ
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 1:1625 STRAITS TURNPIKE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762
Mailing Address - Country:US
Mailing Address - Phone:203-573-9512
Mailing Address - Fax:203-568-2919
Practice Address - Street 1:1655 STRAITS TPKE
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1839
Practice Address - Country:US
Practice Address - Phone:860-965-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035369208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001353698Medicaid
CT001353698Medicaid