Provider Demographics
NPI:1255528857
Name:MARK R. EZEKIEL, M.D., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:MARK R. EZEKIEL, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:EZEKIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-362-3162
Mailing Address - Street 1:2711 N SEPULVEDA BLVD
Mailing Address - Street 2:#320
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2725
Mailing Address - Country:US
Mailing Address - Phone:310-362-3162
Mailing Address - Fax:
Practice Address - Street 1:5750 DOWNEY AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1405
Practice Address - Country:US
Practice Address - Phone:310-362-3162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72866207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W17127Medicare PIN
CAF80609Medicare UPIN