Healthcare Provider Details

I. General information

NPI: 1427144666
Provider Name (Legal Business Name): AHMAD REZA ELLINI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LA VETA AVE SUITE 575
ORANGE CA
92868-4300
US

IV. Provider business mailing address

1010 W LA VETA AVE SUITE 575
ORANGE CA
92868-4300
US

V. Phone/Fax

Practice location:
  • Phone: 714-547-0900
  • Fax: 714-547-2080
Mailing address:
  • Phone: 714-547-0900
  • Fax: 714-547-2080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberD71188
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA122753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: