Healthcare Provider Details

I. General information

NPI: 1851978209
Provider Name (Legal Business Name): MARIAH ELLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST STE 510E
LOS ANGELES CA
90048-5909
US

IV. Provider business mailing address

8631 W 3RD ST STE 510E
LOS ANGELES CA
90048-5909
US

V. Phone/Fax

Practice location:
  • Phone: 310-385-3380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA202227
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: