Provider Demographics
NPI:1780639039
Name:ELLISON, HARRY P (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:P
Last Name:ELLISON
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 1:7777 ALVARADO RD
Mailing Address - Street 2:#108
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-460-2770
Mailing Address - Fax:619-460-2774
Practice Address - Street 1:8881 FLETCHER PARKWAY
Practice Address - Street 2:#102
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-461-1830
Practice Address - Fax:619-797-1484
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG503092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G503090Medicaid
CA00G503090OtherBLUE SHIELD PIN
CA300015048Medicare PIN
CAWG50309DMedicare PIN
CA00G503090OtherBLUE SHIELD PIN
CA00G503090Medicaid
CAWG50309AMedicare PIN
A51632Medicare UPIN