Provider Demographics
NPI:1538128848
Name:EZELL, LYNN E (MD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:E
Last Name:EZELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:E
Other - Last Name:HENDRIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 491028
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049
Mailing Address - Country:US
Mailing Address - Phone:404-605-3247
Mailing Address - Fax:404-609-6645
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-605-3247
Practice Address - Fax:404-609-6645
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023981207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00376065BMedicaid
GA00376065BMedicaid
GA220023964Medicare PIN
GA22BDBXBMedicare PIN
F18110Medicare UPIN