Healthcare Provider Details

I. General information

NPI: 1861449167
Provider Name (Legal Business Name): WILLIAM ELLERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2927 N 7TH AVE
PHOENIX AZ
85013-4102
US

IV. Provider business mailing address

FILE 56765
LOS ANGELES CA
90074-6765
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3153
  • Fax: 602-406-7176
Mailing address:
  • Phone: 602-406-3860
  • Fax: 602-406-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28129
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: