Healthcare Provider Details

I. General information

NPI: 1922044437
Provider Name (Legal Business Name): RANDALL ELLIS JACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 INNOVATION DR STE 300
RENO NV
89511-2215
US

IV. Provider business mailing address

635 INNOVATION DR STE 300
RENO NV
89511-2215
US

V. Phone/Fax

Practice location:
  • Phone: 775-329-6241
  • Fax: 775-329-4921
Mailing address:
  • Phone: 775-329-6241
  • Fax: 775-329-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number13040
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: