Healthcare Provider Details

I. General information

NPI: 1174865455
Provider Name (Legal Business Name): BRIAN EUGENE ELLEDGE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 TENNESSEE ST STE C
REDLANDS CA
92373-8161
US

IV. Provider business mailing address

PO BOX 742353
ATLANTA GA
30374-2353
US

V. Phone/Fax

Practice location:
  • Phone: 909-475-7371
  • Fax:
Mailing address:
  • Phone: 310-482-8403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A14904
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9848744-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: