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General NPI Number Information
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NPI Number | 1992702039
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Entity Type | Individual
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Provider Name | WLADISLAW V ELLIS M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/05/2005
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Last Update Date | 11/16/2018
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Provider Practice Location Address
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Address Line | 13847 MALLORY CT
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City | GRASS VALLEY
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State | CA
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Zip | 95949
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Country | US
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Telephone | 510-849-4703
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Fax | 530-477-6092
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Provider Business Mailing Address
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Address Line | 13847 MALLORY CT
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City | GRASS VALLEY
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State | CA
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Zip | 95949-7658
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Country | US
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Telephone | 510-849-4703
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Fax | 530-477-6092
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | A24351
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License Number State | CA
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