Provider Demographics
NPI:1215113352
Name:MEDEARIS, EDDY
Entity type:Individual
Prefix:MR
First Name:EDDY
Middle Name:
Last Name:MEDEARIS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TAYARI
Other - Middle Name:
Other - Last Name:MEDEARIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2275 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1132
Mailing Address - Country:US
Mailing Address - Phone:510-481-1222
Mailing Address - Fax:
Practice Address - Street 1:1034 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-3225
Practice Address - Country:US
Practice Address - Phone:510-481-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-19
Last Update Date:2008-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor