Provider Demographics
NPI:1861561540
Name:ELLIS, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
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 1:3838 SAN DIMAS ST
Mailing Address - Street 2:SUITE B-100
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2284
Mailing Address - Country:US
Mailing Address - Phone:661-326-0088
Mailing Address - Fax:661-861-0214
Practice Address - Street 1:420 34TH ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2237
Practice Address - Country:US
Practice Address - Phone:661-326-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60702207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G607020Medicaid
CA00G607022Medicare PIN
CAF29285Medicare UPIN
CA00G607020Medicaid