MEDICARE: CARLOS JAVIER EZETA M.S., ME.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1194163980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS JAVIER EZETA M.S., ME.D.

Provider Business Mailing Address
First Line	:	6312 OBANNON DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3043
Country	:	US
Telephone Number	:	702-423-3838
Fax Number	:

Provider Business Practice Location Address
First Line	:	6312 OBANNON DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3043
Country	:	US
Telephone Number	:	702-423-3838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2013
Last Update Date	:	10/01/2014

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