Healthcare Provider Details

I. General information

NPI: 1740817469
Provider Name (Legal Business Name): DANIELLE IMANI ELLIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 RIVERSIDE AVE STE 4
MEDFORD MA
02155-4600
US

IV. Provider business mailing address

PO BOX 24300
NEW YORK NY
10087-4300
US

V. Phone/Fax

Practice location:
  • Phone: 781-396-8224
  • Fax:
Mailing address:
  • Phone: 781-744-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number295571
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: