Basic Information
| Provider Information | |||||||||
| NPI: | 1306824503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | WILLARD | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4150 V ST | ||||||||
| Address2: | SUITE 3400 UCD SCHOOL OF MEDICINE | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167347506 | ||||||||
| FaxNumber: | 9167344810 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 STOCKTON BLVD | ||||||||
| Address2: | MAIN HOSPITAL | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167347506 | ||||||||
| FaxNumber: | 9167344810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A73530 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | A73530 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | A735300 | 05 | CA | MEDICAID |