Provider Demographics
NPI:1760568158
Name:EZEKIEL, SASSOON GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:SASSOON
Middle Name:GEORGE
Last Name:EZEKIEL
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 1:1300 BANCROFT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5147
Mailing Address - Country:US
Mailing Address - Phone:510-483-2600
Mailing Address - Fax:510-483-2605
Practice Address - Street 1:1300 BANCROFT AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5147
Practice Address - Country:US
Practice Address - Phone:510-483-2600
Practice Address - Fax:510-483-2605
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20910174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48935YMedicaid
A86342Medicare UPIN