Provider Demographics
NPI:1548701287
Name:TAREK EZZEDDINE MD INC
Entity type:Organization
Organization Name:TAREK EZZEDDINE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:EZZEDDINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-814-5600
Mailing Address - Street 1:10841 WHITE OAK AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3817
Mailing Address - Country:US
Mailing Address - Phone:909-360-4722
Mailing Address - Fax:
Practice Address - Street 1:10841 WHITE OAK AVE STE 103
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3817
Practice Address - Country:US
Practice Address - Phone:909-360-4722
Practice Address - Fax:909-360-4721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC133690208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty