Provider Demographics
NPI:1154546729
Name:EZZEDDINE, SERENA (MD)
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:EZZEDDINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 NEW BERN AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1247
Mailing Address - Country:US
Mailing Address - Phone:919-350-8228
Mailing Address - Fax:919-350-7918
Practice Address - Street 1:1900 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6616
Practice Address - Country:US
Practice Address - Phone:919-350-8228
Practice Address - Fax:919-350-7918
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN50923207R00000X
NC2010-01471208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC66092UMedicare UPIN