Healthcare Provider Details

I. General information

NPI: 1922022029
Provider Name (Legal Business Name): DOUGLAS JULES ELLISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7592 METROPOLITAN DR SUITE 405-407
SAN DIEGO CA
92108-4428
US

IV. Provider business mailing address

7592 METROPOLITAN DR SUITE 405
SAN DIEGO CA
92108-4428
US

V. Phone/Fax

Practice location:
  • Phone: 619-297-4900
  • Fax: 619-297-5460
Mailing address:
  • Phone: 619-325-8726
  • Fax: 619-325-8728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberG53026
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberG53026
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: