Jack Theodore Ezzedine

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

Practice address

1000 S Fremont Ave
Alhambra, CA 91803-8800

Phone

(626) 457-4240

NPI assigned

Dec 2, 2024

Last updated

Dec 2, 2024By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1733097600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1733097600000",
    "number": "1053137513",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "678 E WALNUT ST UNIT 311",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911012283",
            "telephone_number": "714-713-7774"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 S FREMONT AVE",
            "city": "ALHAMBRA",
            "state": "CA",
            "postal_code": "918038800",
            "telephone_number": "626-457-4240"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "EZZEDINE",
        "first_name": "JACK",
        "middle_name": "THEODORE",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-12-02",
        "last_updated": "2024-12-02",
        "certification_date": "2024-12-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Medical Physician Assistant in Alhambra, CA
• Providers in Alhambra, CA by specialty
• Medical Physician Assistant in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.