Provider Demographics
NPI:1194796078
Name:EZAKI, DEAN A (OD)
Entity type:Individual
Prefix:MR
First Name:DEAN
Middle Name:A
Last Name:EZAKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 WEST NAPA STREET
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476
Mailing Address - Country:US
Mailing Address - Phone:707-938-8116
Mailing Address - Fax:707-938-8143
Practice Address - Street 1:776 WEST NAPA STREET
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476
Practice Address - Country:US
Practice Address - Phone:707-938-8116
Practice Address - Fax:707-938-8143
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55207152W00000X
CA5520T332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680119949OtherEIN
T10018Medicare UPIN
CASD0055200Medicare PIN
CA680119949OtherEIN