Provider Demographics
NPI:1851358063
Name:EZZIDDIN, ABDALLA (MD)
Entity Type:Individual
Prefix:MR
First Name:ABDALLA
Middle Name:
Last Name:EZZIDDIN
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 1:6770 MAYFIELD RD STE 333
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124
Mailing Address - Country:US
Mailing Address - Phone:440-461-0038
Mailing Address - Fax:440-461-8820
Practice Address - Street 1:6770 MAYFIELD RD STE 333
Practice Address - Street 2:
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124
Practice Address - Country:US
Practice Address - Phone:440-461-0038
Practice Address - Fax:440-461-8820
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH036829207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0233732Medicaid
OH0233732Medicaid
OHEZ0438395Medicare ID - Type Unspecified