Provider Demographics
NPI:1306824503
Name:ELLIS, WILLARD S (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:S
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4150 V ST
Mailing Address - Street 2:SUITE 3400 UCD SCHOOL OF MEDICINE
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1460
Mailing Address - Country:US
Mailing Address - Phone:916-734-7506
Mailing Address - Fax:916-734-4810
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:MAIN HOSPITAL
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-7506
Practice Address - Fax:916-734-4810
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA73530207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA735300Medicaid
CAA735301Medicare ID - Type Unspecified
CAA735300Medicaid