Healthcare Provider Details

I. General information

NPI: 1679927834
Provider Name (Legal Business Name): ELEAZAR S. DIAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 10/13/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 JACKSON ST STE 200
RIVERSIDE CA
92503-3947
US

IV. Provider business mailing address

PO BOX 2407
RIVERSIDE CA
92516-2407
US

V. Phone/Fax

Practice location:
  • Phone: 951-353-2769
  • Fax: 951-353-2779
Mailing address:
  • Phone: 808-353-2769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD671
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: