Provider Demographics
NPI:1386647824
Name:ELLISTON, ROBERT RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RICHARD
Last Name:ELLISTON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1750 EL CAMINO REAL
Mailing Address - Street 2:STE 103
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3210
Mailing Address - Country:US
Mailing Address - Phone:650-692-2020
Mailing Address - Fax:650-692-1441
Practice Address - Street 1:1750 EL CAMINO REAL
Practice Address - Street 2:STE 103
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3210
Practice Address - Country:US
Practice Address - Phone:650-692-2020
Practice Address - Fax:650-692-1441
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-28
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
CAG23976207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG23976OtherSTATE MEDICAL LICENSE
AE7560267OtherDEA NUMBER
AE7560267OtherDEA NUMBER
A42115Medicare UPIN