Healthcare Provider Details

I. General information

NPI: 1689296576
Provider Name (Legal Business Name): EZEQUIEL ADONY ANDRADE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 02/18/2024
Certification Date: 02/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 LOMITA BLVD STE 102
HARBOR CITY CA
90710-2084
US

IV. Provider business mailing address

1403 LOMITA BLVD STE 200
HARBOR CITY CA
90710-2086
US

V. Phone/Fax

Practice location:
  • Phone: 424-306-4000
  • Fax:
Mailing address:
  • Phone: 424-306-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA181210
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberA181210
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: