Provider Demographics
NPI:1336228436
Name:ELLISON, SAMUEL FRED (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:FRED
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 UNION ST
Mailing Address - Street 2:SUITE 520
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-4114
Mailing Address - Country:US
Mailing Address - Phone:415-922-3344
Mailing Address - Fax:415-921-7759
Practice Address - Street 1:2001 UNION ST
Practice Address - Street 2:SUITE 520
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-4114
Practice Address - Country:US
Practice Address - Phone:415-922-3344
Practice Address - Fax:415-921-7759
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41459207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28290ZOtherMEDICARE GROUP
CA00A414593Medicare PIN
CAZZZ96273ZMedicare ID - Type UnspecifiedMEDICARE #
CAZZZ28290ZOtherMEDICARE GROUP