=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255528857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK R. EZEKIEL, M.D., A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2007
-----------------------------------------------------
Last Update Date | 06/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5750 DOWNEY AVE SUITE 306
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90712-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-362-3162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2711 N SEPULVEDA BLVD #320
-----------------------------------------------------
City | MANHATTAN BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90266-2725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-362-3162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK R EZEKIEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-362-3162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | G72866
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------