Provider Demographics
NPI:1013042266
Name:FAKTOROVICH, ELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLA
Middle Name:
Last Name:FAKTOROVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DANIEL BURNHAM CT
Mailing Address - Street 2:SUITE 170-C
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-5455
Mailing Address - Country:US
Mailing Address - Phone:415-922-9500
Mailing Address - Fax:415-922-9568
Practice Address - Street 1:1 DANIEL BURNHAM CT
Practice Address - Street 2:SUITE 170-C
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5455
Practice Address - Country:US
Practice Address - Phone:415-922-9500
Practice Address - Fax:415-922-9568
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79065207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02095ZMedicare ID - Type UnspecifiedGROUP ID
CA00G790651Medicare ID - Type UnspecifiedPROVIDER ID