Provider Demographics
NPI:1811460546
Name:AMAR, EDUARDO ELAZEGUI
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:ELAZEGUI
Last Name:AMAR
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 1:3630 MARATHON ST APT 133
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-2867
Mailing Address - Country:US
Mailing Address - Phone:415-786-2528
Mailing Address - Fax:
Practice Address - Street 1:3600 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5730
Practice Address - Country:US
Practice Address - Phone:510-752-8886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24756227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24756Medicaid