Healthcare Provider Details

I. General information

NPI: 1740471879
Provider Name (Legal Business Name): TAREK EZZEDDINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8250 WHITE OAK AVE STE 106
RANCHO CUCAMONGA CA
91730-7679
US

IV. Provider business mailing address

6131 SOFTWIND PL
RANCHO CUCAMONGA CA
91737-7701
US

V. Phone/Fax

Practice location:
  • Phone: 909-360-4722
  • Fax: 909-360-4721
Mailing address:
  • Phone: 909-360-3124
  • Fax: 909-360-4721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC133690
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC133690
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: