Provider Demographics
NPI:1902844939
Name:EZZAT, MONA M (MD)
Entity Type:Individual
Prefix:DR
First Name:MONA
Middle Name:M
Last Name:EZZAT
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 1:9850 GENESEE AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1208
Mailing Address - Country:US
Mailing Address - Phone:858-554-1212
Mailing Address - Fax:858-247-3042
Practice Address - Street 1:9850 GENESEE AVE STE 320
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1208
Practice Address - Country:US
Practice Address - Phone:858-554-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A765560Medicaid
CAP0055643Medicare PIN
CA00A765561Medicare PIN
CAGY786ZMedicare PIN
CA00A765560Medicaid