=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790797835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESHAGH EZRA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 02/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15424 NORDHOFF ST SUITE B
-----------------------------------------------------
City | NORTH HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91343-6951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-891-5500
-----------------------------------------------------
Fax | 818-891-5505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22716 PAUL REVERE DR
-----------------------------------------------------
City | CALABASAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91302-4812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-891-5500
-----------------------------------------------------
Fax | 818-891-5505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A56249
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------