Provider Demographics
NPI:1841254141
Name:ELLIS, DALE SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:SAMUEL
Last Name:ELLIS
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 1:3400 AVENUE OF THE ARTS
Mailing Address - Street 2:J422
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2338
Mailing Address - Country:US
Mailing Address - Phone:714-444-9958
Mailing Address - Fax:
Practice Address - Street 1:18582 BEACH BLVD
Practice Address - Street 2:SUITE 23A
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2000
Practice Address - Country:US
Practice Address - Phone:714-964-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40971207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine