Provider Demographics
NPI:1598749715
Name:EZZEDDINE, DINA ZAYOUR (MD)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:ZAYOUR
Last Name:EZZEDDINE
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 1:3687 MT DIABLO BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3717
Mailing Address - Country:US
Mailing Address - Phone:701-530-6000
Mailing Address - Fax:701-530-6407
Practice Address - Street 1:3687 MT DIABLO BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3717
Practice Address - Country:US
Practice Address - Phone:701-530-6000
Practice Address - Fax:701-530-6407
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073769E174400000X
CAC137543207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN719272Medicare PIN
OHG97138Medicare UPIN
OH4051991Medicare ID - Type Unspecified