Provider Demographics
NPI:1740471879
Name:EZZEDDINE, TAREK (MD)
Entity type:Individual
Prefix:
First Name:TAREK
Middle Name:
Last Name:EZZEDDINE
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 1:10850 CHURCH ST APT Q301
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8049
Mailing Address - Country:US
Mailing Address - Phone:810-814-5600
Mailing Address - Fax:888-376-2776
Practice Address - Street 1:10841 WHITE OAK AVE STE 103
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:810-814-5600
Practice Address - Fax:909-360-4721
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC133690208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1659326395Medicaid
MI0P26070Medicare PIN