Provider Demographics
NPI:1558403733
Name:ETESSAM, ALI (DPT)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:ETESSAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CORPORATE PARK STE 165
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-5161
Mailing Address - Country:US
Mailing Address - Phone:949-207-7377
Mailing Address - Fax:949-207-3227
Practice Address - Street 1:3 CORPORATE PARK STE 165
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-5161
Practice Address - Country:US
Practice Address - Phone:949-207-7377
Practice Address - Fax:949-207-3227
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20329174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0203290Medicaid
CAWPT20329BMedicare ID - Type Unspecified