Provider Demographics
NPI:1235301219
Name:EZZATI, FATEMEH (MD)
Entity Type:Individual
Prefix:DR
First Name:FATEMEH
Middle Name:
Last Name:EZZATI
Suffix:
Gender:F
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:PO BOX 845347 #309
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:617-782-5316
Mailing Address - Fax:617-783-8017
Practice Address - Street 1:2001 INWOOD RD FL 8
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390
Practice Address - Country:US
Practice Address - Phone:214-645-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2546207RR0500X
MA237996207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
001604401Medicare UPIN