Provider Demographics
NPI:1669453676
Name:CARLISLE, ELLIOT RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:RYAN
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17525 VENTURA BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3843
Mailing Address - Country:US
Mailing Address - Phone:818-986-0200
Mailing Address - Fax:818-986-4390
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-788-7343
Practice Address - Fax:818-788-9453
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74780207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A233730Medicaid
CAI30918Medicare UPIN
CA00A233730Medicaid