Provider Demographics
NPI:1790797835
Name:EZRA, ESHAGH (MD)
Entity Type:Individual
Prefix:
First Name:ESHAGH
Middle Name:
Last Name:EZRA
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 1:22716 PAUL REVERE DR
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-4812
Mailing Address - Country:US
Mailing Address - Phone:818-891-5500
Mailing Address - Fax:818-891-5505
Practice Address - Street 1:15424 NORDHOFF ST
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-6951
Practice Address - Country:US
Practice Address - Phone:818-891-5500
Practice Address - Fax:818-891-5505
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A562490Medicaid
CAW18753Medicare ID - Type UnspecifiedMEDICARE GROUP #
CA00A562490Medicaid
CAWA56249GMedicare PIN