Provider Demographics
NPI:1336198910
Name:DAR, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:PAULINE
Other - Last Name:BALLIET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:94220 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-7756
Mailing Address - Country:US
Mailing Address - Phone:541-247-3000
Mailing Address - Fax:541-247-3101
Practice Address - Street 1:500 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9702
Practice Address - Country:US
Practice Address - Phone:541-412-2000
Practice Address - Fax:541-412-2081
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37891-020207P00000X
ND6951207P00000X
CAG86276207P00000X
ORMD167310207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1487696985OtherCURRY HEALTH DISTRICT
OR500605079Medicaid
ORR179441Medicare Oscar/Certification
OR1487696985OtherCURRY HEALTH DISTRICT