Provider Demographics
NPI:1679927834
Name:DIAL, ELEAZAR S (PA-C)
Entity type:Individual
Prefix:
First Name:ELEAZAR
Middle Name:S
Last Name:DIAL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2407
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92516-2407
Mailing Address - Country:US
Mailing Address - Phone:808-353-2769
Mailing Address - Fax:
Practice Address - Street 1:3975 JACKSON ST STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3947
Practice Address - Country:US
Practice Address - Phone:951-353-2769
Practice Address - Fax:951-353-2779
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD671363A00000X
CAPA59155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant