Provider Demographics
NPI:1629005921
Name:JONATHAN C ELLIS MD INC
Entity Type:Organization
Organization Name:JONATHAN C ELLIS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-246-2520
Mailing Address - Street 1:9090 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1848
Mailing Address - Country:US
Mailing Address - Phone:310-246-2520
Mailing Address - Fax:310-659-6237
Practice Address - Street 1:9090 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1848
Practice Address - Country:US
Practice Address - Phone:310-246-2520
Practice Address - Fax:310-659-6237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52023207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG52023Medicare ID - Type Unspecified