Healthcare Provider Details

I. General information

NPI: 1417950304
Provider Name (Legal Business Name): RUBEN A EZQUERRO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date: 03/11/2010
Reactivation Date: 04/28/2010

III. Provider practice location address

21500 PIONEER BLVD STE 104
HAWAIIAN GARDENS CA
90716-2600
US

IV. Provider business mailing address

PO BOX 8877
FOUNTAIN VALLEY CA
92728-8877
US

V. Phone/Fax

Practice location:
  • Phone: 562-402-5311
  • Fax: 562-402-1407
Mailing address:
  • Phone: 562-402-5311
  • Fax: 562-402-1407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: