Healthcare Provider Details

I. General information

NPI: 1841254141
Provider Name (Legal Business Name): DALE SAMUEL ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18582 BEACH BLVD SUITE 23A
HUNTINGTON BEACH CA
92648-2000
US

IV. Provider business mailing address

3400 AVENUE OF THE ARTS J422
COSTA MESA CA
92626-2338
US

V. Phone/Fax

Practice location:
  • Phone: 714-964-4448
  • Fax:
Mailing address:
  • Phone: 714-444-9958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA40971
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: