Provider Demographics
NPI:1598909855
Name:EZATVAR, MANIJEH (RPT)
Entity Type:Individual
Prefix:
First Name:MANIJEH
Middle Name:
Last Name:EZATVAR
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 NEWBURY RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-6435
Mailing Address - Country:US
Mailing Address - Phone:805-375-0001
Mailing Address - Fax:805-375-2221
Practice Address - Street 1:1000 NEWBURY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-6435
Practice Address - Country:US
Practice Address - Phone:805-375-0001
Practice Address - Fax:805-375-2221
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT19200AMedicare PIN
CAQ27316Medicare UPIN