Provider Demographics
NPI:1033268503
Name:SAMADANI, ELLIE E (MD)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:E
Last Name:SAMADANI
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 1:3737 MORAGA AVE
Mailing Address - Street 2:SUITE A105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5404
Mailing Address - Country:US
Mailing Address - Phone:858-273-0200
Mailing Address - Fax:858-273-0619
Practice Address - Street 1:3737 MORAGA AVE
Practice Address - Street 2:SUITE A105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5404
Practice Address - Country:US
Practice Address - Phone:858-273-0200
Practice Address - Fax:858-273-0619
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83066207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G830660Medicaid
G35801Medicare UPIN
WG83066CMedicare ID - Type UnspecifiedINDIV PROVIDER NUMBER