Provider Demographics
NPI:1083851950
Name:ELLIS, JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8677 VILLA LA JOLLA DR
Mailing Address - Street 2:1208
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-2354
Mailing Address - Country:US
Mailing Address - Phone:760-845-0509
Mailing Address - Fax:
Practice Address - Street 1:8677 VILLA LA JOLLA DR
Practice Address - Street 2:1208
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-2354
Practice Address - Country:US
Practice Address - Phone:760-845-0509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1979213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist