Provider Demographics
NPI:1215393855
Name:FASSASSI, EZDEAN
Entity Type:Individual
Prefix:
First Name:EZDEAN
Middle Name:
Last Name:FASSASSI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10914 GEORGIA AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-4792
Mailing Address - Country:US
Mailing Address - Phone:240-343-3193
Mailing Address - Fax:
Practice Address - Street 1:10914 GEORGIA AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-4792
Practice Address - Country:US
Practice Address - Phone:240-343-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist