Provider Demographics
NPI:1053137513
Name:EZZEDINE, JACK THEODORE
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:THEODORE
Last Name:EZZEDINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:678 E WALNUT ST UNIT 311
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2283
Mailing Address - Country:US
Mailing Address - Phone:714-713-7774
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8800
Practice Address - Country:US
Practice Address - Phone:626-457-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty