Provider Demographics
NPI:1790782902
Name:ELLINWOOD, JEANINE M (MD)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:M
Last Name:ELLINWOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-9512
Mailing Address - Country:US
Mailing Address - Phone:530-621-7820
Mailing Address - Fax:
Practice Address - Street 1:6520 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9512
Practice Address - Country:US
Practice Address - Phone:530-621-7820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110131834OtherRAILROAD MEDICARE
CAC006OtherTRICARE
CA110131834OtherRAILROAD MEDICARE