Provider Demographics
NPI:1083796098
Name:SAN BUENAVENTURA, ELLEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:MARIE
Last Name:SAN BUENAVENTURA
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 1:5161 N STONE HOUSE PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750
Mailing Address - Country:US
Mailing Address - Phone:520-749-5889
Mailing Address - Fax:
Practice Address - Street 1:5161 N STONEHOUSE PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-9671
Practice Address - Country:US
Practice Address - Phone:520-749-5889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14454207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ240119OtherAHCCCS
AZ240119-10Medicaid
370016065OtherRAILROAD MCR
370016065OtherRAILROAD MCR
D00246Medicare UPIN