Provider Demographics
NPI:1912932849
Name:ELLISON, BRUCE E (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
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 1:2940 WHIPPLE AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2857
Mailing Address - Country:US
Mailing Address - Phone:650-366-4585
Mailing Address - Fax:650-366-3896
Practice Address - Street 1:2940 WHIPPLE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-2857
Practice Address - Country:US
Practice Address - Phone:650-366-4585
Practice Address - Fax:650-366-3896
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84392207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A843920OtherBLUE SHIELD PROVIDER ID #
CA00A843920Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CAI04789Medicare UPIN