Provider Demographics
NPI:1689860389
Name:ELLIS, CHANDRA VARNER (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDRA
Middle Name:VARNER
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHANDRA
Other - Middle Name:
Other - Last Name:VARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:307 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3709
Mailing Address - Country:US
Mailing Address - Phone:415-491-1210
Mailing Address - Fax:888-849-4257
Practice Address - Street 1:7700 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3902
Practice Address - Country:US
Practice Address - Phone:210-575-2876
Practice Address - Fax:888-849-4257
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS51612086S0122X, 2086S0102X, 208600000X, 2086S0122X
GA842622086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX408628201Medicaid