Provider Demographics
NPI:1922151240
Name:ELLIS, THOMAS R (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:ELLIS
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:450 SUTTER STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4206
Practice Address - Country:US
Practice Address - Phone:415-393-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80146207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG48658Medicare UPIN
CA00G801460Medicare ID - Type Unspecified
CADR755ZMedicare PIN