Provider Demographics
NPI:1023011087
Name:EZZATI, MASHALLAH (MD)
Entity Type:Individual
Prefix:DR
First Name:MASHALLAH
Middle Name:
Last Name:EZZATI
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 1:23361 EL TORO RD
Mailing Address - Street 2:107
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6922
Mailing Address - Country:US
Mailing Address - Phone:949-235-9818
Mailing Address - Fax:949-305-9500
Practice Address - Street 1:23361 EL TORO RD
Practice Address - Street 2:107
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6922
Practice Address - Country:US
Practice Address - Phone:949-235-9818
Practice Address - Fax:949-305-9500
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42933208D00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAD88167Medicare UPIN
MAJ02945Medicare ID - Type Unspecified