Provider Demographics
NPI:1639303944
Name:ELLIS, CARA DAVIDSON (MD)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:DAVIDSON
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARA
Other - Middle Name:C
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 SE STONE MILL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6998
Practice Address - Country:US
Practice Address - Phone:360-816-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60296002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500649465Medicaid
WAP01178829OtherRAILROAD MEDICARE - PHS
WAG8911779Medicare PIN