Healthcare Provider Details

I. General information

NPI: 1235186313
Provider Name (Legal Business Name): KENT C ELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 MARINA VILLAGE PKWY STE 100
ALAMEDA CA
94501-1078
US

IV. Provider business mailing address

1080 MARINA VILLAGE PKWY STE 100
ALAMEDA CA
94501-1078
US

V. Phone/Fax

Practice location:
  • Phone: 103-377-9505
  • Fax: 602-685-3808
Mailing address:
  • Phone: 103-377-9505
  • Fax: 602-685-3808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number33041
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC142177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: