Provider Demographics
NPI:1396930376
Name:NII-MOI, EBENEZER A (MD)
Entity type:Individual
Prefix:DR
First Name:EBENEZER
Middle Name:A
Last Name:NII-MOI
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 1:1107 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5602
Mailing Address - Country:US
Mailing Address - Phone:903-758-2610
Mailing Address - Fax:903-212-7689
Practice Address - Street 1:705 E MARSHALL AVE STE 3000
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5661
Practice Address - Country:US
Practice Address - Phone:906-758-2610
Practice Address - Fax:903-758-7081
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD431796207V00000X
TXQ8114207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8GK198OtherBCBS TX
TX3651184-01Medicaid
TX3651184-01Medicaid