Healthcare Provider Details

I. General information

NPI: 1306876263
Provider Name (Legal Business Name): JONATHAN C ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9090 WILSHIRE BLVD SUITE 101
BEVERLY HILLS CA
90211-1848
US

IV. Provider business mailing address

9090 WILSHIRE BLVD SUITE 101
BEVERLY HILLS CA
90211-1848
US

V. Phone/Fax

Practice location:
  • Phone: 310-246-2520
  • Fax: 310-659-6237
Mailing address:
  • Phone: 310-550-0400
  • Fax: 310-285-0498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG52023
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: