Provider Demographics
NPI:1417950304
Name:EZQUERRO, RUBEN A (DPM)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:A
Last Name:EZQUERRO
Suffix:
Gender:M
Credentials:DPM
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 8877
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-8877
Mailing Address - Country:US
Mailing Address - Phone:562-402-5311
Mailing Address - Fax:562-402-1407
Practice Address - Street 1:21500 PIONEER BLVD
Practice Address - Street 2:STE 104
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-2600
Practice Address - Country:US
Practice Address - Phone:562-402-5311
Practice Address - Fax:562-402-1407
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-11-30
Deactivation Date:2010-03-11
Deactivation Code:
Reactivation Date:2010-04-28
Provider Licenses
StateLicense IDTaxonomies
CAE4042213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40420OtherBLUE SHIELD
CA000E40420Medicaid
CA000E40421Medicaid
CA000E40420Medicaid
CA000E40421Medicaid
CACZ126YMedicare PIN
CAE4042AMedicare PIN
CA5183780001Medicare NSC
CACZ126ZMedicare PIN
CAE4042Medicare PIN