Provider Demographics
NPI:1235186313
Name:ELLER, KENT C (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:C
Last Name:ELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 MARINA VILLAGE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1078
Mailing Address - Country:US
Mailing Address - Phone:103-377-9505
Mailing Address - Fax:602-685-3808
Practice Address - Street 1:1080 MARINA VILLAGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1078
Practice Address - Country:US
Practice Address - Phone:103-377-9505
Practice Address - Fax:602-685-3808
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ330412084P0800X
CAC1421772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ875437Medicaid
AZ875437Medicaid
AZF63344Medicare UPIN