Provider Demographics
NPI:1154315604
Name:ELLIS, KAREN A (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:ELLIS
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:PO BOX 2311
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91313-2311
Mailing Address - Country:US
Mailing Address - Phone:818-718-9500
Mailing Address - Fax:818-718-9507
Practice Address - Street 1:501 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4809
Practice Address - Country:US
Practice Address - Phone:818-847-4422
Practice Address - Fax:818-847-4429
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54822207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G548220Medicaid
CAWG54822HMedicare PIN
CAWG54822FMedicare PIN
CAWG5822DMedicare PIN
CAF34958Medicare UPIN
CAWG54822CMedicare PIN