Provider Demographics
NPI:1083075303
Name:ELLIS, W ALEXANDER
Entity Type:Individual
Prefix:
First Name:W ALEXANDER
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 N CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7601 HOSPITAL DR
Practice Address - Street 2:103
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5408
Practice Address - Country:US
Practice Address - Phone:916-681-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA140782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine