Provider Demographics
NPI:1639415227
Name:MCINTOSH, ELLYN GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLYN
Middle Name:GRACE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3700 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5733
Mailing Address - Country:US
Mailing Address - Phone:310-212-4705
Mailing Address - Fax:310-212-2941
Practice Address - Street 1:3700 W 190TH ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504-5733
Practice Address - Country:US
Practice Address - Phone:310-212-4705
Practice Address - Fax:310-212-2941
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG553772083X0100X
MT102802083X0100X
FLME1073542083X0100X
GA646892083X0100X
OK277262083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine