Provider Demographics
NPI:1104544089
Name:EID, ELLIS ALAN (IDC)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:ALAN
Last Name:EID
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34101 FARENHOLT AVE BLDG 14
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-7000
Mailing Address - Country:US
Mailing Address - Phone:619-532-7968
Mailing Address - Fax:
Practice Address - Street 1:USS GEORGE WASHINGTON
Practice Address - Street 2:CVN 73
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09550-2873
Practice Address - Country:US
Practice Address - Phone:757-534-3448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1122592096OtherDODID