1922022029 NPI number — DOUGLAS JULES ELLISON M.D.

Table of content: DOUGLAS JULES ELLISON M.D. (NPI 1922022029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922022029 NPI number — DOUGLAS JULES ELLISON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLISON
Provider First Name:
DOUGLAS
Provider Middle Name:
JULES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922022029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7592 METROPOLITAN DR
Provider Second Line Business Mailing Address:
SUITE 405
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108-4428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-325-8726
Provider Business Mailing Address Fax Number:
619-325-8728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7592 METROPOLITAN DR
Provider Second Line Business Practice Location Address:
SUITE 405-407
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-4428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-297-4900
Provider Business Practice Location Address Fax Number:
619-297-5460
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  G53026 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZH0000X , with the licence number: G53026 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G530260 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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