Provider Demographics
NPI:1184778094
Name:BARNETT, ELLEN (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BARNETT
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 1:175 CONCOURSE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8217
Mailing Address - Country:US
Mailing Address - Phone:707-284-9206
Mailing Address - Fax:707-284-9254
Practice Address - Street 1:175 CONCOURSE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8217
Practice Address - Country:US
Practice Address - Phone:707-284-9206
Practice Address - Fax:707-284-9254
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA368950208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680452627OtherTAX ID#
CAA368950OtherLICENSE #
CA00A368951Medicare ID - Type UnspecifiedMEDICARE #
CAA28213Medicare UPIN