1184946386 NPI number — RUBEN EZQUERRO DPM INC

Table of content: (NPI 1184946386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184946386 NPI number — RUBEN EZQUERRO DPM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUBEN EZQUERRO DPM INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184946386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8877
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOUNTAIN VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92728-8877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-402-5311
Provider Business Mailing Address Fax Number:
562-402-5311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21500 PIONEER BLVD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
HAWAIIAN GARDENS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90716-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-402-5311
Provider Business Practice Location Address Fax Number:
562-402-1407
Provider Enumeration Date:
02/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
EZQUERRO
Authorized Official First Name:
RUBEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
562-402-5311

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E4042 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000E40421 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000E40420 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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