MEDICARE: SAMANTHA ROSE ELLIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207N00000X	Dermatology Physician	A144841	CA

General Provider Information

NPI Number	:	1174918098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA ROSE ELLIS M.D.

Provider Business Mailing Address
First Line	:	3301 C ST
Second Line	:	SUITE 1400
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-3300
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 SAN RAMON VALLEY BLVD STE 102
Second Line	:
City	:	DANVILLE
State	:	CA
Zip	:	94526-4021
Country	:	US
Telephone Number	:	925-838-4900
Fax Number	:	925-838-4920

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2015
Last Update Date	:	04/18/2019

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