Provider Demographics
NPI:1073573168
Name:ELLISON, GREGG ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ALAN
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1105 LAS TABLAS RD
Mailing Address - Street 2:STE F
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465
Mailing Address - Country:US
Mailing Address - Phone:805-434-1851
Mailing Address - Fax:805-434-1193
Practice Address - Street 1:1105 LAS TABLAS RD
Practice Address - Street 2:STE F
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9731
Practice Address - Country:US
Practice Address - Phone:805-434-1851
Practice Address - Fax:805-434-1193
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA33338207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A27114Medicare UPIN
CA00A333380Medicare ID - Type Unspecified