Healthcare Provider Details

I. General information

NPI: 1023011087
Provider Name (Legal Business Name): MASHALLAH EZZATI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23361 EL TORO RD 107
LAKE FOREST CA
92630-6922
US

IV. Provider business mailing address

23361 EL TORO RD 107
LAKE FOREST CA
92630-6922
US

V. Phone/Fax

Practice location:
  • Phone: 949-235-9818
  • Fax: 949-305-9500
Mailing address:
  • Phone: 949-235-9818
  • Fax: 949-305-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC42933
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberC42933
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: