Provider Demographics
NPI:1013025576
Name:KEST, EZRA (MD)
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:
Last Name:KEST
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 1:16030 VENTURA BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4487
Mailing Address - Country:US
Mailing Address - Phone:818-501-4421
Mailing Address - Fax:310-276-1250
Practice Address - Street 1:16030 VENTURA BLVD STE 240
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:818-501-4421
Practice Address - Fax:310-276-1250
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2019-02-28
Deactivation Date:2012-07-06
Deactivation Code:
Reactivation Date:2015-09-17
Provider Licenses
StateLicense IDTaxonomies
CAG58408207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D92051Medicare UPIN
00G584080Medicare ID - Type Unspecified