Provider Demographics
NPI:1023463981
Name:ELLIS, VIVIANA SALOM (MD)
Entity type:Individual
Prefix:
First Name:VIVIANA
Middle Name:SALOM
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4458 MEDICAL CENTER DRIVE, SUITE 705 SAN ANTONIO, TX 78
Mailing Address - Street 2:SUITE 705
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-614-1000
Mailing Address - Fax:
Practice Address - Street 1:4458 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 705
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-614-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXBP10057063207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology