Provider Demographics
NPI:1265412993
Name:ELLIS, SELENA W (MD)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:W
Last Name:ELLIS
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 1:3000 COLBY ST STE 302
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2058
Mailing Address - Country:US
Mailing Address - Phone:510-644-2282
Mailing Address - Fax:510-644-1744
Practice Address - Street 1:3000 COLBY ST STE 302
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2058
Practice Address - Country:US
Practice Address - Phone:510-644-2282
Practice Address - Fax:510-644-1744
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA713372084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD0533ZMedicare PIN