Provider Demographics
NPI:1508838541
Name:EBENEZER, DANIEL JAYAKUMAAR (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAYAKUMAAR
Last Name:EBENEZER
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 1:2 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE # 175
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3049
Mailing Address - Country:US
Mailing Address - Phone:916-782-2146
Mailing Address - Fax:916-782-4299
Practice Address - Street 1:2 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE # 175
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3049
Practice Address - Country:US
Practice Address - Phone:916-782-2146
Practice Address - Fax:916-782-4299
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32625207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ06970ZOtherBLUE SHIELD
CAGR0094900Medicaid
ZZZ26246ZMedicare PIN
ZZZ06970ZOtherBLUE SHIELD
CAGR0094900Medicaid