Provider Demographics
NPI:1265611362
Name:EBILANE, ANANIAS E (MD)
Entity type:Individual
Prefix:
First Name:ANANIAS
Middle Name:E
Last Name:EBILANE
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 1:13429 S HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5803
Mailing Address - Country:US
Mailing Address - Phone:310-644-8683
Mailing Address - Fax:310-644-0132
Practice Address - Street 1:13429 S HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5803
Practice Address - Country:US
Practice Address - Phone:310-644-8683
Practice Address - Fax:310-644-0132
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34021208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144231093OtherNPI TYPE 2
CA00A340210Medicaid
WA34021EOtherMEDICARE PTAN
1144231093OtherNPI TYPE 2