Provider Demographics
NPI:1023231917
Name:ELLIS, DAMON MATTHEW (OD)
Entity type:Individual
Prefix:DR
First Name:DAMON
Middle Name:MATTHEW
Last Name:ELLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3527 HARRISON ST.
Mailing Address - Street 2:UNIT 1
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611
Mailing Address - Country:US
Mailing Address - Phone:510-847-1593
Mailing Address - Fax:
Practice Address - Street 1:3205 GRAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2740
Practice Address - Country:US
Practice Address - Phone:510-444-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11878T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0018780Medicaid
CAU99562Medicare UPIN
CASD0018780Medicare ID - Type UnspecifiedMEDICARE