Provider Demographics
NPI:1205721941
Name:MAO, EZRA JEREMIAH RUAW
Entity type:Individual
Prefix:MR
First Name:EZRA
Middle Name:JEREMIAH RUAW
Last Name:MAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10730 SHEDDEN DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2327
Mailing Address - Country:US
Mailing Address - Phone:909-272-6543
Mailing Address - Fax:
Practice Address - Street 1:34448 YUCAIPA BLVD STE A
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2412
Practice Address - Country:US
Practice Address - Phone:754-790-9353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician