Healthcare Provider Details

I. General information

NPI: 1285605212
Provider Name (Legal Business Name): SAMUEL EJADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S RM 240
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 THE CITY DR S BLDG. 56 RM. 240
ORANGE CA
92868-3201
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-8000
  • Fax: 714-456-2242
Mailing address:
  • Phone: 714-456-8000
  • Fax: 714-456-7142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number228707
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number36682
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number25MA07608600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberC55259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: